THE  UNIVERSITY 
OF  ILLINOIS 
LIBRARY  , 


\ 


THE 


SCIE^^CE   A^^D  AET 


OF 


MIDWIFEEY. 


BY 

WILLIAM  THOMPSON  LUSK,  A.M.,  M.D., 

PR0FF.8S0E  OF  OBSTETRICS  AUD   THE  DISEASES   OF  WOMEN   AND   CHILDREN  IN  THE  BELLEVITE  HOSPITAL 
MEDICAL    COLLEGE  ;    CONSULTING    PHYSICIAN  TO  THE    MATERNITY   HOSPITAL ;  VISITING  PHYSICIAN 
TO   THE    EMERGENCY    HOSPITAL;    GYNAECOLOGIST   TO    THE    BELLEVUE    HOSPITAL;  FELLOW 
OF   THE    AMERICAN    GYNECOLOGICAL    SOCIETY;    CORRESPONDING    FELLOW  OF  THE 
OBSTETRICAL   SOCIETIES   OF   EDINBURGH   AND   LONDON  ;  ETC.,  ETC. 


WITH  NUMEROUS  ILLUSTRATIONS. 


NEW  YORK: 
D.    APPLETON   AND  COMPANY, 

1,  3,  AND  5  BOND  STREET. 

1882. 


COPYRIGHT  BY 

APPLETON  AND  COMPANY, 
1881. 


rvJ  TO 


^        r  O  E  D  Y  C  E    B  A  R  K  E  E,  M.  D.,  LL.  D., 

IN  EECOGNITION  OF  HIS  EMINENCE 

^  AS    A    TVEITEE,    TEACHEE,    AND  PHYSICIAN, 

AND  IN  GRATEFUL  ACKNOWLEDGMENT 
J  OF 

HIS  GENEROSITY  TO'*VAED  THE  YOITNGER  MEMBERS  OF  HIS  PROFESSION, 


h.Vi 


WITH  THE  AFFECTIONATE  REGARD  OF  HIS  FEIEND, 

THE  AUTHOR. 


o 
O 

CO 

§ 


253738 


PREFACE. 


In  the  preparation  of  this  work,  my  purpose  has  been  to  present 
to  the  reader  a  fair  statement  of  the  changes  which  have  been  made 
by  modern  investigation  in  the  views  entertained  respecting  the 
physiology  and  pathology  of  pregnancy,  labor,  and  childbed ;  and 
I  have  endeavored  to  show  that  with  advancing  knowledge  the  art 
of  midwifery  has  ceased  to  rest  upon  empirical  rules,  and  is  already, 
w'ith  rare  exceptions,  the  natural  outcome  of  scientitic  principles. 
To  insure  accuracy,  I  have  spared  no  pains  to  subject  the  doctrines 
taught  to  rigorous  clinical  tests ;  and  I  have  everywhere  sought  to 
supplement  and  correct  my  own  personal  experiences  by  the  re- 
corded observations  of  others. 

Because  of  the  strangeness  of  much  of  the  new  obstetrical  litera- 
ture, I  have  considered  it  desirable  to  make  copious  references  to 
recent  authorities.  At  the  same  time,  I  hope  that  these  references 
may  prove  of  service  to  such  as  desire  to  examine  for  themselves 
original  sources  of  information.  If  I  have  given  sj^ecial  promi- 
nence to  the  labors  of  German  investigators,  it  has  not  been  due  to 
a  lack  of  appreciation  of  valuable  contributions  from  other  foreign 
and  home  sources,  but  because,  with  large  hospitals  and  with  state 
encouragement,  the  obstetrical  writers  of  Germany  have  of  late 
years  occupied  a  vantage-ground  of  which,  to  their  credit,  they 
have  been  prompt  to  avail  themselves. 

To  make  room  for  the  results  of  recent  scientific  investigation, 
much  of  purely  historical  and  controversial  matter  usually  found  in 
obstetrical  treatises  has  been  omitted. 


vi 


PREFACE. 


Special  stress  has  been  laid  upon  the  operations  of  midwifery 
and  the  influence  exerted  bj  the  more  common  varieties  of  con- 
tracted pelvis  in  the  production  of  anomalies  pertaining  to  preg- 
nancy and  labor. 

In  reviewing  the  field  of  practicCj  I  have  not  found  it  possible 
to  discover  any  natural  line  of  division  between  obstetrics  and  gy- 
naecology. 'No  man  merits  the  reputation  of  a  good  accoucheur 
unless  he  possess  a  thorough  appreciation  not  only  of  the  immediate 
dangers  but  of  the  far-reaching  consequences  of  the  faulty  j)ractice 
of  his  art ;  nor  can  his  equipment  be  looked  upon  as  otherwise  than 
defective  unless  it  include  an  ability  to  repair  surgical  injuries  at 
the  time  of  their  occurrence. 

In  submitting  this  work  to  the  critical  judgment  of  the  medical 
profession,  it  is  my  earnest  hope  that  the  principles  which  have 
governed  my  own  practice  may  prove  a  safe  guide  to  others. 


47  East  Thirty-fourth  Street, 
September,  1881. 


CONTENTS. 


PHYSIOLOGICAL  ANATOMY, 

CHAPTER  I.  PAGE 
Female  Oegaxs  of  Gexeratiox       .  .  .  .  .  .  1 

The  pudendum. — Labia  niajora. — Clitoris. — Labia  minora. — Vestibule. — The  bulbs 
of  the  vestibule — Meatus  urethrae. — Sebaceous  glands. — Mucous  glands. — 
Vaginal  orifice. — Hymen. — Vagina. — Vessels  of  vagina. — Uterus. — Fallopian 
tubes. — Ovaries. — Vessels  of  uterus  audits  appendages. — Nerves  of  uterus. — 
Lymphatics. — Development  of  the  female  organs  of  generation. — Arrests  of 
development. 


PHYSIOLOGY  OF  THE  OVTTM. 
CHAPTER  IL 

Develop.mext  of  toe  Otum  .  .  .  .  .  ,  .33 

The  Graafian  follicles  and  the  ovum. — Discharge  of  the  ova  from  the  ovary,  and 
the  formation  of  the  corpus  luteum. — The  migration  of.  the  ovum. — Fecun- 
dation.— Changes  taking  place  in  the  ovum  subsequent  to  fecundation. — 
Nourishment  of  the  embryo. — The  allantois  and  chorion. — The  deciduae. — 
The  placenta;  its  development  and  structure. — Formation  of  the  umbilical 
cord. — The  aumiotic  fluid. 

CHAPTER  IH. 

Development  of  the  Fcetus  .  .  .  .  .  .  .59 

Area  germinativa. — Primitive  trace. — Dorsal  plates. — Tubus  mcduUaris. — Cerebral 
vesicles. — Chorda  dorsalis. — Vertebral  plates. —  Abdominal  plates. — Central 
plates. — Development  of  the  bony  skeleton. — Development  of  the  intestine, 
face,  lungs,  liver,  pancreas,  bladder,  heart. — Development  of  foetus  in  suc- 
cessive months  of  pregnancy. — F(x>tus  at  term, — Fetal  cranium. — The  atti- 
tude, position,  and  presentation  of  the  foetus. 


PHYSIOLOGY  OF  PREGNANCY. 
CHAPTER  IV. 

Changes  effected  ix  the  Maternal  Orgtanism  by  Pregnancy  .         .  82 

Changes  in  the  sexual  apparatus  and  neighboring  organs. — Changes  in  the  uterus. 
— Explanation  of  apparent  shortening  of  cervix. — Changes  in  the  vagina, 
vulva,  abdomen,  navel,  breasts,  nipple. — Functional  disturbances  of  bladder. 
— Constipation.-^GMema. — Changes  effected  in  the  entire  organism. 


viii 


CONTENTS. 


CHAPTER  V. 

The  Diagnosis  of  Peegxancy 

Signs  of  pregnancy. — Suppression  of  menses. — Nausea. — Salivation. — Breasts. — 
Increase  of  abdomen, — Changes  of  the  os  and  cervix. — Quickening. — Bal- 
lottement. — Fetal  heart-beat. — Uterine  bruit. — Funic  souffle. — Interrogation 
of  the  patient. — Methods  of  physical  examination. — Inspection  of  abdomen. 
— Palpation. — Auscultation. — The  vaginal  touch. — Distinction  between  first 
and  subsequent  pregnancies. — Diagnosis  of  death  of  foetus. — Duration  of 
pregnancy. — Prediction  of  day  of  confinement  from  date  of  last  menstrua- 
tion.— Date  of  quickening. — Size  of  uterus. 


PAGE 

.  95 


F  EEGNA  NGY. 
CHAPTEPv  VL 

The  Management  of  Peegnancy     .  .         .  .  .  .115 

Hygiene  of  pregnancy. — The  disorders  of  pregnancy. — The  blood-changes  of  preg- 
nancy.— Pernicious  anaemia. — Hydrsemic  oedema. — Varicose  veins. — Nausea 
and  vomiting. — Heart-burn. — Insalivation. — Pruritus. — Face-ache. — Cephalal- 
gia.— Insomnia. 

LABOR, 
CHAPTER  VII. 

The  Physiology  of  Laboe  and  its  Clinical  Phenomena  .  .122 

Causes  of  labor. — Uterine  contractions. — Action  of  labor-pains  upon  the  uterine 
walls. — Contraction  of  ligaments. — Action  of  abdominal  muscles. — Action  of 
vagina. — The  pain  of  labor. — General  influence  of  labor-pains  upon  the  or- 
ganism.— -Precursory  symptoms  of  labor. — First,  second,  and  third  stages  of 
labor. — Duration. — Action  of  the  expellent  forces. 

CHAPTER  VIII. 

Mechanism  of  Laboe  ........  139 

Anatomical  factors, — Anatomy  of  pelvis. — Sacrum. — Coccyx. — Ossa  innominata. 
— The  ilia. — The  pubes,— The  ischia. — Articulations  of  the  pelvis. — Sacro- 
iliac articulations. — Symphysis  pubis. — The  pelvic  ligaments. — Obturator 
membrane. — Sacro-sciatic  ligaments. — Inclination  of  the  pelvis.— The  pelvis 
as  a  whole. — The  pelvic  planes. — Plane  of  the  brim. — Plane  of  the  outlet. — 
Planes  of  the  cavity, — Ischial  planes. — Pelvic  axis. — Differences  between 
male  and  female  pelvis. — Differences  between  the  iirfantile  and  adult  pelvis. 
— The  soft  parts  of  the  pelvis, — The  perineal  floor, — The  head  of  the  foetus 
fit  term. — Sutures  and  fontanelles. — The  diameters  of  the  fetal  head, — The 
articulation  of  the  head  with  the  spinal  column, 

CHAPTER  IX. 

Mechanism  of  Laboe. — {Continued.)  .  ,  ,  .  .  167 

Presentations:  natural,  unnatural,  normal. — Vertex  presentations:  frequency,  po- 
sitions.— Manner  in  which  head  enters  pelvis. — Positions.- — Normal  mechajiism 
of  labor. — Descent  and  flexion. — Rotation. — ^Extension. — External  rotation. 
— Expulsion  of  the  trunk. — Abnormal  mechanism  (vertex  presentations). — 
Mechanism  of  occipito-posterior  positions. — Configuration  of  the  head  in  ver- 
tex presentations. — Molding. — Scal^^tumor. — Diagnosis  of  vertex  presenta- 
tions. 

CHAPTER  X. 

Mechanism  of  Laboe. — [Continued.)  .  .  .  .  .182 

Face  presentations. — Frequency. — Causes. — Mechanism. — Descent  and  extension, 
— Rotation. — Flexion. — External  Rotation. — Abnormal  mechanism. — Configu- 


CONTENTS. 


ix 


ration  of  head. — Diagnosis. — Prognosis. — Treatment. — Brow  presentations. — 
Breech  presentations. — Causes. — Diagnosis. — Mechanism. — Irregular  mechan- 
ism.— Configuration. — Prognosis. — Treatment. 

CHAPTER  XI. 

Conduct  of  Noemal  Labok  .  .    ■      .  .  .  ".  .  202 

Preliminary  preparations. — Examination  of  the  patient. — Management  of  the  first 
stage. —  Management  of  the  second  stage. — Preservation  of  the  perinoeum. — 
Delivery  of  the  shoulders. — Tying  the  cord. — Third  or  placental  stage. — Care 
of  patient  after  delivery. — Treatment  of  perineal  lacerations. — Anaesthetics 
in  midwifery. 

CHAPTER  XII. 

Multiple  Pregxaxcies  axd  their  Management    .  .  .  .221 

Frequency.  —  Origin. — Varieties. — Acardia. — Weight.  —  Unequal  development.  — 
Superfetation. — Diagnosis. — Labor. — Presentations. — Simultaneous  entrance 
of  both  children  into  the  pelvis. — Locking. — Prognosis. — Conduct  of  labor. 


THE  PUERPERAL  STATE. 
CHAPTER  XIII. 

The  Physiology  and  Management  of  Childbed  ....  230 
The  puerperal  state  borders  closely  upon  pathological  conditions. — Post-partum 
chill. — Temperature. — The  pulse. — General  functions. — Retention  of  urine. 
— Loss  of  weight. — Involution. — Separation  of  the  decidua. — Closure  of  the 
sinuses. — The  cervix. — The  vagina. — Position  of  uterus. — After-pains. — The 
lochia. — The  secretion  of  milk. — Anatomical  considerations. — Milk-fever. — 
Composition  of  milk. — Diagnosis  of  the  puerperal  state. — The  new-born  in- 
fant.— Changes  in  circulation. — The  navel. — Tumor  upon  the  presenting  part. 
— Digestion. — Skin. — Icterus. — Loss  of  weight. — Management  of  puerperal 
state. — Sleep. — Passing  urine. — Visits  of  physician. — Washing  the  vagina. — 
Diet. — Laxatives. — Nursing. — Duration  of  lying-in  period. — Care  of  new-born 
infant. — Bath. — Cord. — Nursing. — Wet-nurses. — Artificial  feeding. 


THE  PATHOLOGY  OF  PREGNANCY. 
CHAPTER  XIV. 

Accidental  Complications. — Abnormalities  of  the  Uterus       .  .  249 

'  Variola. — Rubeola. — Scarlatina. — Scarlatina  pucrperalis. — Cholera. — Typhus,  ty- 
phoid, and  relapsing  fever. — Malarial  fever. — Icterus. — Cardiac  diseases. — 
Pneumonia. — Emphysema,  chronic  pleurisy,  and  empyema. — Phthisis. — Syphi- 
lis.— Chorea. — Surgical  operations  during  pregnancy. — Double  uterus. — Ante- 
version  and  anteflexion. — Retroversion. — Retroflexion. — Prolapse  of  uterus 
and  vagina. — Hernias. 

CHAPTER  XV. 

Diseases  of  the  Decidua. — Diseases  of  the  Ovum         .  .  .  270 

Endometritis  decidua:  1.  Chronica;  2.  Tuberosa;  3.  Catarrhalis. — Anomalies  of 
the  placenta. — Anomalies  of  form;  of  position;  of  development;  of  circula- 
tion.— Placentitis. — Degenerations. — Syphilis. — Anomalies  of  the  amnion  and 
of  the  amniotic  fluid. — Hydramnion. — I)eficiency  of  amniotic  fluid. — Anoma- 
lies of  the  umbilical  cord ;  torsion  ;  knots ;  hernias  ;  coiling  of  the  cord  ; 
cysts ;  stenoses  of  vessels ;  marginal  implantations. — Ilydatidiform  mole. 

CHAPTER  XVI. 

The  Premature  Expulsion  of  the  Ovum  .....  291 
Causes  of  abortion. — Disposition  to  abortion. — Immediate  causes. — Symptoms. — 
Moles. — Incomplete  abortions. — Diagnosis. — Prognosis. — Treatment. — Pro- 


X  CONTENTS. 

PAGE 

phylaxis. — Arrest  of  threatened  abortion. — Treatment  of  inevitable  abortion. 
— Treatment  of  neglected  abortion. — Removal  of  fibrinous  polypi. — Treat- 
ment of  miscarriage. 

CHAPTER  XVII. 

EXTEA-UTEEIXE  PrEGXANCY       .......  309 

Definition. — Tubal  pregnancy. — Pregnancy  in  rudimentary  cornu. — Interstitial 
pregnancy. — Tubo-abdominal  and  tubo-ovarian  pregnancy. — Ovarian  preg- 
nancy. —  Abdominal  pregnancy.  —  Symptoms. — Terminations. — Diagnosis. — 
Treatment,  in  cases  of  early  gestation. — Cases  of  advanced  gestation  (foetus 
living). — Cases  of  gestation  prolonged  after  the  death  of  the  foetus. 


OBSTETRIC  SURGERY. 
CHAPTER  XVIII. 

The  Induction  of  Peemattjee  Laboe         .....  326 

Induction  of  premature  labor.^ — Indications. — Contracted  pelvis. — Habitual  death 
of  foetus. — Diseases  which  imperil  the  life  of  the  mother. — Operation. — 
Catheterisatio  uteri. — Intra-uterine  injections. — Rupture  of  membranes. — 
Mechanical  dilatation  of  cervix. — Vaginal  douches. — Tampon.— Choice  of 
methods. — Care  of  the  child. — Artificial  abortion. 

CHAPTER  XIX. 

FoECEPs  .........  334 

History. — Varieties  of  forceps ;  short  forceps,  long  forceps. — Action  of  forceps. 
— Indications. — Preparations. — Forceps  at  outlet. — Operation;  introduction; 
locking  ;  tractions  ;  removal. — Forceps  at  brim  ;  opei'ation. — Axis-traction 
forceps, — Forceps  in  occipito-posterior  positions ;  in  face  presentations. 

CHAPTER  XX. 

EXTEACTION  IN  FoOT  AND  BeEECH  PeESENTATIONS   ....  354 

Extraction  in  pelvic  presentations. — Attitude  of  the  physician. — Prognosis. — Posi- 
tion.— Extraction  of  trunk. — Extraction  by  the  feet ;  by  the  breech. — ^lan- 
agement  of  the  cord. — Liberation  of  the  arms, — Exceptional  cases. — Extrac- 
tion of  the  head. — Smellie's  method. — Veit's  method. — Head  at  brim. — 
Prague  method. — Forceps  to  the  after-coming  head. 

CHAPTER  XXI. 

Version  .         .  .  .         .  .  .  .  .306 

Cephalic  version, — External  method. — Combined  method. — Busch. — D'Outrepont, 
— Wright. — Hohl. — Braxton  Hicks. — Podalic  version, — Bi-polar  method. — 
Internal  version. — Neglected  version. — Use  of  the  fillet. 

■    CHAPTER  XXII. 

'Craniotomy  and  Embeyotomy         ......  377 

Craniotomy. — Indications. — Operation. — Perforators. — Method  of  perforating. — 
Extraction  after  perforation. — Forceps. — Cephalotribe. — Action  of  the  ccph- 
alotribe.  —  Objections.  —  Application  of  the  cephalotribe.  —  Cranioclast. — 
Crotchet  and  blunt  hook. — Cephalotomy. — Embryotomy. — Exenteration. — 
Decapitation. 

CHAPTER  XXIII. 

'CESAREAN  Section. — Operations  of  Thomas  and  Poeeo  .  .  .  390 

Caesarean  section. — History. — Indications. — Operation. — After-treatment, — Prog- 
nosis.— Operation  of  Porro. — Operation  of  Thomas. 


CONTENTS. 


xi 


THE  PATHOLOGY  OF  LABOR. 

CHAPTER  XXIV.  paoe 

AXOMALIES  OF  THE  ExPELLEXT  FoECES  .  .  .  .  .419 

Precipitate  labors. — Tardy  labors. — Irregular  pains  in  the  first  stage  of  labor. — 
Treatment  of  protracted  first  stage. — Irregular  pains  in  the  second  stage. — 
Treatment  of  protracted  second  stage. — On  the  use  of  ergot  in  labor. — Ir- 
regular pains  in  the  third  stage ;  treatment. — Painful  labors :  from  hysteria  ; 
from  rheumatism ;  from  intestinal  irritation ;  from  inflammatory  changes. 


CHAPTER  XXV. 

COXTRACTED  PeLTES      ........  432 

Varieties. — Frequency. — Diagnosis. — Pelvic  measurements. — Forms  of  the  con- 
tracted pelvis. — Justo-minor  pelves. — Flattened  non-rachitic  pelves. — Rachitic 
flattened  pelves. — Generally  contracted,  flattened  pelves. — Irregular  forms. 
— Pseudo-osteomalacia. — Scoliosis. — Kyphosis. — Influence  of  contracted  pel- 
ves during  pregnancy  and  labor. — Influence  upon  the  uterus. — Influence  upon 
the  presentation. — Influence  upon  the  pains. — Influence  upon  the  fii^st  stage 
of  labor. — Influence  upon  the  mechanism  of  labor. — Effects  of  pressure  upon 
the  maternal  tissues. — Influence  upon  the  fetal  head. — Effects  of  pressure 
upon  the  integuments  ;  upon  the  cranium. — Prognosis. 


CHAPTER  XXVI. 

Treatment  of  Coxtracted  Pelves  ......  460 

Cases  of  extreme  pelvic  contraction,  rendering  delivery  per  vias  naturcdcs  impos- 
sible.—Cases  indicating  craniotomy  or  premature  labor. — Cases  Avhere  ex- 
traction of  a  living  child  at  term  is  possible. — Premature  labor, — Version. 
— Forceps. — Expectant  treatment. 


CHAPTER  XXVII. 
Rare  Forms  of  Pelvic  Distortion  .  .  .  .  .  .481 

The  Nacgele  oblique  pelvis :  morbid  anatomy,  etiology,  diagnosis,  mechanism  of 
labor  in,  prognosis,  treatment. — The  kypliotic  pelvis :  morbid  anatomy,  etiol- 
ogy, diagnosis,  prognosis. — Scolio-rachitic  pelvis:  anatomical  characters. — 
Robert's  pelvis:  anatomy,  etiology,  diagnosis,  prognosis. — Spondylolisthetic 
pelvis:  anatomical  characters,  diagnosis,  prognosis. — Funnel-shaped  pelvis. 
— Osteomalacia. — Pelvis  narrowed  by  exostoses. — Divided  symphysis. 

CHAPTER  XXVIII. 
Abnormalities  of  the  Sexual  Organs  .....  500 
Atresia  of  the  genital  canal. — Vulvar  atresia. — Vaginal  atresia. — Cystocele. — Rec- 
tocele. — Retention  of  urine. — Impacted  calculi. — Vaginal  hernias. — Cystic 
degeneration  of  the  vaginal  wall. — Vaginismus. — Echinococci. — Uterine  atre- 
sia,— Conglutinatio  orificii  externi. — Cicatricial  atresia. — Rigidity. — Throm- 
bus of  the  cervix. — Symptoms  of  atresia. — Note  on  treatment. — Tumors. — 
Fibroids, — Cancer. — Ovarian  tumors. 


CHAPTER  XXIX. 

Abnormalities  of  the  Foetus  which  offer  an  Obstruction  to  Delivery,  513 
Premature  ossification  of  the  cranium. — Hydrocephalus. — Encephalocele. — Hydro- 
thorax. — Ascites. — Other  causes  of  abdominal  distention. — Tumors  of  the 
trunk. — Monstrosities. — Double  monsters. — Acardiaci.— Anenccphalous  mon- 
sters.— Abnormal  positions. — Spontaneous  version. — Spontaneous  evolution. 


CHAPTER  XXX. 

Eclampsia       ........  .^>526 

Definition. — Clinical  history. — Prognosis,  pathology,  and  etiology. — Treatment. 


xii 


CONTENTS. 


CHAPTER  XXXI.  page 

POST-PAETUM  HjEMOEEHAGE  AND  RETAINED  PlACENTA  .  .  .  539 

Normal  agencies  for  checking  haemorrhage. — Distm-bances  of  contractility,  of  re- 
tractility, of  thrombus  formation. — Treatment. — ^Method  of  securing  contrac- 
tion and  retraction. — Treatment  of  cerebral  anaemia. — Retained  placenta. 

CHAPTER  XXXn. 

Placenta   Pe.^:via.  —  Accidental   H.emoeehage.  —  Inveesion  of  the 

Uteeus  .........  552 

Situation. — Varieties. — Frequency. — Causes  of  haemorrhage. — Clinical  features. — 
Prognosis. — Diagnosis. — Treatment. — Accidental  haemorrhage. — Inversion  of 
the  uterus. 

CHAPTER  XXXIII. 
Ruptuees  of  the  Genital  Canal    .  .  .  .  .  .564 

Rupture  of  the  uterus. — Etiology. — Pathological  anatomy. — Symptoms  and  diag- 
nosis.— Treatment. — Prophylaxis. — Treatment  after  rupture. — Rupture  lim- 
ited to  the  peritoneal  covering  of  the  uterus. — Perforation  from  pressure. — 
Lacerations  of  the  vaginal  portion. — Laceration  of  the  vagina. — Laceration 
of  the  vulva. — Thrombus  of  the  vulva  and  vagina. — Rupture  of  the  pelvic 
articulations. 

CHAPTER  XXXIV. 
Peolapse  of  the  Funis,  etc.  ......  582 

Prolapsed  funis. — Asphyxia  neonatorum. — Collapse  and  sudden  death  during  labor 
and  childbed  from  thrombosis,  from  embolism,  and  from  entrance  of  air  into 
the  circulation. — On  the  extraction  of  the  child  in  case  of  death  of  the 
mother  in  pregnancy  or  labor. — Tympanites  uteri. 


DISEASES  OF  CHILDBED. 

CHAPTER  XXXV. 

Pueepeeal  Feyee       ........  602 

Frequency. — Pathological  anatomy. — Endoeolpitis  and  endometritis. — Metritis  and 
parametritis. — Pelvic  and  diffused  peritonitis. — Phlebitis  and  phlebo-throm- 
bosis. — Nature  of  puerperal  fever. — Clinical  history. — Symptoms  of  endome- 
tritis and  endoeolpitis ;  of  parametritis  and  perimetritis  ;  of  general  perito- 
nitis; of  septicaemia  lymphatica  ;  of  septicaemxia  venosa  ;  of  pure  septicaemia. 


CHAPTER  XXXVI. 
Pueepeeal  Fevee. — {Continued.)      ......  630 

Causes. — The  atmosphere. — Relations  to  zymotic  diseases. — Season  of  year. — So- 
cial state. — The  prevention  of  puerperal  fever. — The  treatment  of  puerperal 
fever. — Vaginal  and  uterine  injections ;  opium  ;  leeches  ;  laxatives ;  quinine ; 
salicylate  of  sodium  ;  veratrum  viride ;  digitalis  ;  alcohol ;  cold. — Treatment 
of  pelvic  exudations. 

CHAPTER  XXXVIL 

Pueepeeal  Insanity. — Phlegmasia  Alba   Dolens. — Diseases  of  the 

Beeasts  .........  652 

The  insanity  of  pregnancy,  of  childbed,  of  lactation. — Phlegmasia  alba  dolens. — 
Defective  milk  secretion. — (ialactorrlui^a. — Sore  nipples. — Subcutaneous  in 
flammation  of  the  breast. — Submammary  abscess. — Parenchymatous  mastitis. 
— Galactocele. 


LIST  OP  ILLUSTRATIONS. 


FIGURE  PAGE 

1.  The  external  parts  of  generation  (the  thighs  are  separated  so  as  to  place  the 

parts  upon  the  stretch).    (Luschka.)   2 

2.  Lateral  view  of  the  ei-ectile  structures  of  the  external  organs  of  the  female  (from 

Kobelt),  two  thirds   3 

3.  Front  view  of  the  erectile  structures  of  the  external  organs  of  the  female. 

(Kobelt.)   5 

4.  Section  through  the  female  pelvis.    (Kohlrausch  modified  by  Spiegelberg.)   8 

5.  The  vagina  (exposed  in  its  entire  length  by  the  removal  of  the  posterior  wall). 

(Henle.)   9 

6.  Complete  genital  organs  of  the  female.    (Beigel.)   10 

7.  Virgin  uterus.    (Sappey.)   12 

8.  Virgin  uterus  opened  posteriorly.    (Bandl.)   13 

9.  Uterus  of  a  woman  who  has  borne  children.    (Bandl.)   14 

10.  Section  through  the  mucous  membrane  of  a  normal  virgin  uterus,  magnified  about 

forty  diameters.    (Kundrat  and  Engclmann.)   17 

11.  Section  through  uterus  showing  cavity.    (Weber.)   17 

12.  Posterior  lateral  view  of  the  uterus,  with  portion  of  lig.  latum,  oviduct,  and  ovary. 

(Henle.)   18 

13.  Section  through  Fallopian  tube     19 

14.  Section  through  ampulla  (thirty  diameters).    (Luschka.)   20 

15.  Longitudinal  section  of  ovary  from  a  person  aged  eighteen  (eight  diameters). 

(Ilenle.)   21 

16.  Arterial  vessels  in  a  uterus  ten  days  after  delivery.    (Lusclika.)   22 

17.  Uterine  and  utero-ovarian  veins  (plexus  pampiniformis).    (Sappey.)   24 

18.  Nerves  of  the  uterus.    (Frankenhaeuser.)     26 

19.  Rudimentary  sexual  organs.    (Luschka.)   28 

20.  Uterus  and  its  appendages  in  the  fretus  at  the  end  of  the  fourth  month  (natural 

size).    (Courty.)   29 

21.  Uterus  unicornis  from  a  young  child,  posterior  aspect.    (Pole.)   29 

22.  Double  uterus  and  vagina  from  a  girl  aged  nineteen.    (Eisenmann.)   30 

23.  Uterus  bicornis,  double  cavity  and  double  vagina,  from  a  girl  seventeen  years  of 

age.    (Courty.)   31 

24.  Uterus  cordiformis,  double  natural  size.    (Kiissmaul.)   31 

25.  Uterus  septus  bilocidaris.    (Cruveilhier.)   32 

26.  Section  of  Wolffian  body,  with  rudimentary  ovary  (embryo  of  chick,  fourth  day 

of  incubation).    (Waldeyer.)   33 

27.  Vertical  section  of  an  ovary  of  a  human  foetus  thirty-two  weeks  old.   (Waldeyer.)  34 

28.  Portion  of  vertical  section  through  ovary  of  bitch.    (Waldeyer.)   35 

29.  Ovum  from  a  Graafian  follicle  in  the  rabbit.    (Waldeyer.)   36 


xiv  OF  ILLUSTRATIONS. 

FIGURE  PAGE 

30.  SperraatozOca  from  the  human  subject  (magnitied  eight  hundred  diameters). 

(Luschka.)   41 

31.  Ovum  of  the  nephelis  vulgaris,  showing  retraction  of  vitellus  and  the  penetration 

of  the  spermatozoa  through  the  vitelline  membrane  (magnified  three  hundred 

diameters).    (Robin.)   42 

32.  Segmentation  of  the  ovum.    (Haeckel.)   43 

33.  Blastodermic  vesicle  from  the  uterus  of  the  rabbit.    (Bischoff.)   44 

34.  Section  through  area  germinativa  in  the  egg  of  a  rabbit,  showing  the  thickening 

of  the  ectoderm  (ect.)  at  that  point,  as  contrasted  with  the  ectoderm  of  the 

blastodermic  vesicle  beyond  the  area  germinativa  {v(j!.).    (Kolliker.)   45 

35.  Area  germinativa,  from  the  ovum  of  a  rabbit,  enlarged  about  ten  diameters. 

(Ilaeckel.)   45 

36.  Transverse  section  of  egg  in  early  stage  of  development,    (Dalton.)   46 

37.  Transverse  section  through  the  embryo  of  the  chick  a  few  hours  after  the  com- 

mencement of  incubation   46 

38.  Transverse  section  through  the  embryo  of  a  chick  at  the  end  of  the  first  day  of 

incubation  (magnified  twenty  diameters)   47 

39.  Transverse  section  through  the  embryo  of  a  chick  on  the  second  day  of  incuba- 

tion (magnified  one  hundred  diameters)   47 

40.  Section  through  the  ovum  of  chick  after  development  of  umbilical  vesicle   48 

41.  Diagram  showing  early  stage  in  development  of  amnion   49 

42.  Diagram  showing  completion  of  the  amnion  and  formation  of  the  chorion   49 

43.  Human  embryo,  at  the  third  week,  showing  villi  covering  the  entire  chorion. 

(Haeckel.)  ,   50 

44.  Formation  of  permanent  chorion   50 

45.  Human  embryos,  at  the  ninth  and  the  twelfth  week.    (Erdl.)  Facinf/  50 

46.  Formation  of  decidua,  first  stage                                                                 .  51 

47.  Formation  of  decidua,  completed   52 

48.  Diagram  showing  the  branching  of  the  villi  and  the  connection  of  the  larger 

trunks  with  the  placenta.    (Langhans.)    54 

49.  Diagram  of  uterus  and  placenta  in  the  fifth  month.    (Leopold.)   56 

50.  Area  germinativa,  from  the  ovum  of  a  rabbit  (enlarged  about  ten  diametei-s). 

(Haeckel.)   59 

51.  Development  of  the  nervous  system  of  the  chick.    (Longet.)   60 

52.  Development  of  spinal  cord  and  brain  of  human  subject.    (Longet.)   60 

53.  Transverse  section  through  the  embryo  of  a  chick  at  the  end  of  the  first  day  of 

incubation  (magnified  twenty  diameters)   61 

54.  Human  embryo  between  the  twenty-fifth  and  twenty-eighth  days,  showing  the 

visceral  arches.    (Coste.)   63 

55.  Mouth  of  embryo  of  thirty-five  days.    (Coste.)     64 

56.  Mouth  of  embryo  of  forty  days.    (Coste.)   64 

57.  Development  of  the  lungs.    (Longet.)   65 

58.  Heart  of  embryo  chick  in  the  earliest  stages  of  formation.    (Remak.)   66 

59.  Diagram  of  heart  and  first  arterial  vessels.    (Quain.)   67 

60.  Area  vasculosa.    (Bischoff.)   68 

61.  Diagram  of  the  vascular  arches,  with  transformations  giving  rise  to  the  perma-  • 

nent  arterial  vdssels.    (Rathke.)   69 

62.  Diagram  of  the  fetal  circulation.    (Flint.)   71 

63.  Fetal  head,  side-view.    (Hodge.)   77 

64.  Fetal  head,  viewed  from  above.    (Ilodge.)   77 

£5.  Attitude  of  foetus  m  w^cro.    (Tarnier  ct  CKantreuil.)   78 

66.  Appearance  of  vaginal  portion  in  primipara;  end  of  ninth  month.    (Taylor.).  . .  87 

67.  Appearance  of  cervix  in  multipara  ;  ninth  month.    (Taylor.)   88 


LIST  OF  ILLUSTRATIONS.  XV 

Fir.ZTRE  PAGE 

68.  Showing  the  convexity  of  the  anterior  wall  produced  by  the  weight  of  the  ovum,  89 

69.  Diagram  representing  changes  in  the  cervix  resulting  from  pressure  of  child's 

head  on  anterior  wall.    (Lott.)   90 

70.  Diagram  from  computing  pregnancy.    (Scliultze.)   112 

TL  Schultze  diagram   113 

72.  The  mucous  membrane  of  the  uterus.    (Engelmann.)   124 

73.  Transverse  section,  dotted  line  representing  shape  of  uterus  during  a  pain. 

(Lahs.)   127 

74.  Longitudinal  section,  dotted  line  representing  elevation  of  fundus  during  a 

pain.    (Lahs.)   127 

75.  Diagram  representing  the  changes  in  the  thickness  of  the  uterine  w^alls  during 

labor.    (Lahs.)   128 

76.  Section  through  a  frozen  corpse.    Stage  of  expulsion.    (Braune.)   131 

77.  The  uterus  and  parturient  canal.    Fa'tus  removed.    (Braune.)   132 

78.  Longitudinal  section  through  walls  of  uterus  in  eighth  month  of  pregnancy. 

(Bandl.)   136 

79.  Sacrum  and  coccyx  (anterior  surface)   140 

80.  Section  of  sacrum  and  coccyx   141 

81.  Os  innominatum,  before  consolidation.    (Luschka.)   141 

82.  Outer  sui'face  of  os  innominatum   142 

83.  Inner  surface  of  os  innominatum   143 

84.  Section  through  the  left  sacro-iliac  articulation  (natural  size).    (Luschka.)...  144 

85.  Section  of  symphysis.    (Luschka.)   144 

86.  Front  view  of  pelvis,  with  ligaments.    (Quain.)   145 

87.  Transverse  section  through  pelvis,  to  show  the  sacro-seiatic  ligaments.  (Tar- 

nier  et  Chantreuil.)   146 

88.  Section  showing  the  inclination  of  the  pelvis  according  to  Naegele.  (Tarnier 

et  Chantreuil.)   146 

89.  Diagram  showing  oscillatory  movements  of  sacrum.    (Duncan.)   148 

90.  Anterior  half  of  the  pelvis  ,   148 

91.  Posterior  half  of  the  pelvis   149 

92.  Diameters  at  brim.    (Martin.)   150 

93.  Diameters  at  outlet.    (Martin.)   150 

94.  Section  showing  the  inclination  of  the  pelvis  according  to  Naegele.  (Tarnier 

et  Chantreuil.)   151 

95.  Axis  represented  upon  a  vertical  section  through  a  plaster  cast  of  the  pelvic 

cavity.    (Ilodge.)   152 

96.  Vertical  section  of  a  female  infantile  pelvis.    (Fehling.)   153 

97.  98.  Diagrammatic  representations  of  sections  through  the  infantile  and  adult 

pelves.    (Schroeder.)   154 

99.  Pelvis  covered  with  the  soft  parts,  with  removal  of  bladder,  uterus,  and  rectum  156 

100.  Section  of  pelvis,  showing  the  pyramidal  muscles.    (Tarnier  et  Chantreuil.).  .  157 

101.  Section  of  pelvis,  showing  the  internal  obturator  muscle.    (Tarnier  et  Chan- 

treuil.)  158 

102.  Muscles  of  the  perineal  floor,  as  seen  from  the  abdominal  cavity   158 

103.  Antero-posterior  section  of  the  perineal  floor.    (Tarnier  et  Chantreuil.)    159 

104.  Muscles  of  the  perina?um.    (Henle.)   161 

105.  The  parturient  canal.    (Hodge.)   162 

106.  Lateral  view  of  fetal  skull.    (Ilodge.)   163 

107.  Fetal  head,  as  seen  from  above.    (Hodge.)   163 

108.  Antero-posterior  and  vertical  diameters  of  the  fetal  head.    (Tarnier  et  Chan- 

treuil.)  165 

109.  Diagram  showing  transverse  diameters  of  fetal  head.    (Tarnier  et  Chantreuil.)  185 


xvi  LIST  OF  ILLUSTRATIONS. 

FIGURE  PAGE 

110.  Figure  illustrating  the  mechanism  of  labor  in  occipito-antcrior  deliveries. 

(After  Schultze.)   170 

111.  Vertex  presentation ;  child  surrounded  by  amniotic  fluid.    (Tarnier  et  Chan- 

treuil.)   171 

112.  Attitude  of  foetus.    (Ribemont.)   175 

113.  Figure  illustrating  the  mechanism  of  labor  in  occipito-posterior  positions. 

(After  Schultze.)   178 

114.  Outlines  showing  difference  between  head  of  child  at  birth  and  four  days  sub- 

sequent to  delivery.    (Budin.)   179 

115.  Figure  showing  shape  of  head  in  occipito-posterior  deliveries.    (Tarnier  et 

Chantreuil.)   180 

116.  Method  of  performing  external  palpation.    (Tarnier  et  Chantreuil.)   181 

117.  Attitude  of  the  head  in  face  presentations.    (Ribemont.)   185 

118.  Engagement  of  the  head  in  face  presentations.    (Tarnier  et  Chantreuil.)   186 

119.  Mechanism  of  face  presentations.    (Schultze.)   187 

120.  Face  presentation,  chin  to  the  rear.    (Hodge.)   187 

121.  Outline  of  head  born  with  face  presenting   188 

122.  Same  head  five  days  later.    (Budin.)     188 

123-125.  Diagrams  showing  Schatz's  method  of  converting  face  presentations  into 

vertex  presentations   191 

126.  Outline  of  head  after  delivery,  the  brow  presenting.    (Budin.)   192 

127.  Brow  presentation,  subsequently  converted  into  that  of  the  face.  (Maternity 

Hospital.)   193 

128.  Presentation  of  the  breech.    Left  dorso-anterior  position.    (Tarnier  et  Chan- 

treuil.)  196 

129.  Illustration  showing  lateral  inflexion  of  the  trunk  during  delivery  of  the  breech  198 

130.  Showing  shape  of  head  in  breech  presentations.    (Budin.)   200 

131.  Showing  the  effect  of  premature  tractions  upon  the  cord.    (Schultze.)   216 

132.  Showing  normal  position  of  placenta.    (Duncan.)   217 

133.  Author's  case  of  acardia   222 

134.  Twin  pregnancy,  both  heads  presenting.    (Tarnier  et  Chantreuil.)   226 

135.  Twin  pregnancy,  head  and  breech  presenting.    (Tarnier  et  Chantreuil.)   227 

136.  Mammary  gland.    (Liegeois.)   238 

137.  Section  through  acinus  from  breast  of  a  nursing  woman.    (Billroth.)   239 

138.  Knot  of  umbilical  cord.    (Leyman.)   280 

139.  Insertio  velamentosa.    (Lobstein.)   282 

140.  Hydatidiform  mole   284 

141.  Ovum,  with  imperfectly  developed  decidua ;  outer  surface  of  vera.    (Duncan.)  293 

142.  Uterus,  with  basis  of  a  fibrinous  polypus  after  an  abortion.    (Frankel.)   297 

143.  Tubal  pregnancy.    (N.  Sommer.)   311 

144.  Pregnancy  in  rudimentary  cornu.    (Kiissmaul,  observed  by  Heyfelder.)   312 

145.  Interstitial  pregnancy.    (Hennig.)     313 

146.  Bifurcation  of  tubal  canal.    (Hennig.)   314 

147.  Forceps  of  Chamberlen   336 

148.  Forceps  of  Smellie   336 

149.  Levret's  forceps   337 

150.  Naegele's  forceps   338 

151.  Simpson's  forceps   338 

152.  Hodge's  forceps   339 

153.  Introduction  of  blades     343 

154.  Blade  adjusted  to  the  head  at  outlet   344 

155.  Method  of  making  tractions   346 

156.  Position  of  operator  when  head  is  on  perinjBum   347 


LIST  OF  ILLUSTRATIONS.  Xvii 

FIGCRE  PAGE 

157.  Forceps  applied  to  head  at  brim     849 

158.  Taylor's  narrow-blaJed  forceps   350 

159.  Author's  modification  of  Tarnier's  forceps   352 

160.  Taylor's  method  in  mcnto-posterior  positions  of  the  face. .  .    354 

161.  Method  of  seizing  both  feet.    (Scanzoni.)   357 

162.  Method  of  seizing  the  breech.    (Scanzoni.)   358 

163.  Combined  traction  upon  mouth  and  shoulders.    (Chailly-Honore.)   363 

164.  The  method  of  extracting  the  trunk     364 

165.  The  Prague  method  of  extracting  head.    (Scanzoni.)   365 

166.  Chin  arrested  at  symphysis.    (Chailly-Honore.)   365 

167.  D'Outrepont's  method,  modified  by  Scanzoni   368 

168.  Version  in  head  presentations.    (Chailly-Honore.)   372 

1 69.  170.  Version  in  transverse  presentations ;  direct  method  of  seizing  feet.  (Braun.)  373 

171.  Method  of  reaching  an  extremity  by  first  passing  the  hand  around  the  breech. 

(Scanzoni.)   374 

172.  Braun's  repositor   375 

173.  Catheter  used  as  repositor   376 

174.  Scissors  of  Smellie   378 

175.  Simpson's  perforator     379 

176.  Blot's  perforator   379 

177.  Hodge's  craniotomy  scissors   379 

178.  Thomas's  perforator   379 

179.  Trephine  perforator  ■   380 

180.  Operation  for  perforating  the  child's  head    381 

181.  Cephalotribe  of  Blot   384 

182.  Cephalotribe  of  Scanzoni   385 

183.  The  author's  cephalotribe    385 

184.  Simpson's  cranioclast   389 

185.  Braun's  cranioclast   390 

186.  Head  of  child  after  delivery  with  the  cranioclast.    (Simpson.)   390 

187.  Meigs's  craniotomy-forceps  (modified  by  Professor  I.  E.  Taylor)   392 

188.  Crotchet   393 

189.  Dr.  Taylor's  right-angled  blunt  hook   393 

190.  Segment  removed  by  the  Tarnicr  forceps-saw.    (P.  Thomas.)   394 

191.  Braun's  decapitating  hook   396 

192.  Braun's  method  of  decapitation   396 

193.  Embryotome  of  P.  Thomas   397 

194.  Embryotome  adjusted  around  the  neck  of  the  child   398 

195.  Method  of  extracting  foetus  in  the  Caesarean  operation.    (Stoltz.)   403 

196.  Baudelocque's  pelvimeter   434 

197.  Schultze's  pelvimeter   435 

198.  Normal  inclination  of  the  symphysis  pubis.    (Spiegelberg.)   437 

199.  Diminution  of  angle  between  symphysis  and  pelvic  brim   437 

200.  Increase  of  angle  between  symphysis  and  pelvic  brim   437 

201.  Specimens  from  the  Wood  ^luscum  (Bellevue  Hospital)    440 

202.  Flattened  rachitic  pelvis.    (Wood's  Museum.)   442 

203.  Small  symmetrical  rachitic  pelvis.    (Wood's  Museum.)   445 

204.  Pseudo-osteomalacia.    (N^aegele.)   445 

205.  Scoliosis.    (Litzmann.)   446 

206.  Pressure-mark  upon  skull.    (Dohrn.)   457 

207.  Base  of  sk^ll   471 

208.  Method  of  employing  supra-pubic  pressure.  Head  in  the  pelvic  cavity.  (Munde.)  472 

209.  Naegele  oblique  pelvis.    (From  specimen  in  the  Wood  Museum.)   481 


xviii 


LIST  OF  ILLUSTRATIONS. 


FIGURE  PAGE 

210.  Specimen  of  kyphotic  pelvis.    (Litzmann.)   486 

211.  Specimen  of  scolio-rachitic  pelvis.    (Litzmann.)   488 

212.  Robert's  pelvis.    (Lambl.)   490 

213.  Spondylolisthetic  pelvis.    (Kilian.)   491 

214.  Osteomalacia.    (Specimen  from  Wood's  Musemn.)   495 

215.  Osseous  tumors  filling  pelvic  cavity.    (Naegele.)   498 

216.  Author's  case  of  acardia   520 

217.  Birth  with  doubled  body.    (Chiara.)     524 

218.  Neglected  shoulder  presentation.  Section  through  frozen  corpse.  (Kleinwiichter.)  525 

219.  Diagrams  representing  relaxed  and  contracted  uterus.    (Breisky.)   540 

220.  Bimanual  compression  of  uterus.    (Breisky.)   544 

221.  Diagram  showing  the  unavoidable  placental  separation  as  a  consequence  of  cer- 

vical dilatation..   554 

222.  Diagram  showing  dangerous  thinning  of  the  lower  segment,  owing  to  the  non- 

descent  of  the  head  in  contracted  pelvis.    (Bandl.)  ,   566 

223.  Case  of  ruptured  uterus  (anterior  surface)..   567 

224.  Retraction  in  a  case  of  shoulder  presentation.    (Bandl.)   571 

225.  Robcrton's  rcpositor   587 

226.  Specimens  of  micrococci.    (Doleris.)   613 


THE 

SCIENCE  AXD  AET  OF  MIDWIFERY. 


PHYSIOLOGICAL  AlfATOMY. 


CHAPTER  I. 

FEMALE  ORGANS  OF  GENERATION. 

The  pudendum. — Labia  majora. — Clitoris. — Labia  minora. — Vestibule. — The  bulbs  of 
the  vestibule. — Meatus  urethrae. — Sebaceous  glands. — Mucous  glands. — Vaginal  ori- 
fice.— Hymen. — Vagina. — Vessels  of  vagina. — Uterus. — Fallopian  tubes. — Ovaries. 
— Vessels  of  uterus  and  its  appendages. — Nerves  of  uterus. — Lymphatics. — Devel- 
opment of  the  female  organs  of  generation. — Arrests  of  development. 

The  female  organs  of  generation  may  be  properly  divided  as  fol- 
lows :  1.  The  external  parts,  or  pudendum,  and  the  vagina.  2.  The 
uterus,  Fallopian  tubes,  and  ovaries. 

The  external  parts  and  vagina  are  chiefly  concerned  in  the  act  of 
copulation.  As  they  likewise  constitute  the  channel  through  which 
the  child  passes  during  parturition,  a  knowledge  of  their  anatomical 
structure  becomes  of  importance  to  those  who  would  practice  the  ob- 
stetric branch  of  medicine. 

The  internal  organs,  i.  e.,  the  uterus.  Fallopian  tubes,  and  ovaries, 
assume  obstetrical  importance  in  connection  with  the  parts  they  play 
in  gestation.  Thus,  the  ovary  furnishes  the  germ  from  which  the 
new  being  is  developed.  The  Fallopian  tube  receives  the  germ,  and 
conveys  it  to  the  uterus.  In  the  uterus,  the  fecundated  germ  ob- 
tains the  nutritive  materials  necessary  for  its  subsequent  growth  and 
development. 

I.  The  External  Parts  of  Gekeration"  an^d  Vagina. 

The  Pudendum. — The  pudendum  comprises  all  those  parts  which 
are  perceptible  externally.  It  includes  the  mons  Veneris,  the  labia, 
the  clitoris,  the  nympha3,  and  the  hymen.    It  is  situated  at  the  lower 


PHYSIOLOGICAL  ANATOMY. 


opening  of  the  pelvis,  and  has  a  wedge-shape,  whence  the  term  cun- 
nus,  i.  e.,  cuneus.  Its  base  is  formed  by  the  mons  Vefieris,  a  fatty 
cushion,  abundantly  supplied  with  hair,  which  covers  the  symphysis 
pubis.  As  it  follows  the  curvature  of  the  lower  portion  of  the  trunk, 
in  extreme  inclination  of  the  pelvis  it  is  sometimes  directed  so  far 
backward  as  to  render  difficult  the  introduction  of  the  speculum  and 
the  accomplishment  of  the  sexual  act.  It  is  divided  in  the  median 
line  by  the  rima  2^udencli,  Avhich  extends  from  the  mons  Veneris  to  the 
perinseum.  Upon  each  side  of  the  rima  there  are  two  longitudinal, 
slightly  curved,  and  rounded  folds  of  integument,  which  rest  upon 
cushions  of  adipose  areolar  tissue.    These  folds  constitute  the  so-called 


Fig.  1. — The  external  parts  of  generation  (the  tliisrhs  are  separated  so  as  to  place  the  parts 
upon  th.e  stretch).  1,  labia  majora;  2,  glans  clitoridis  ;  3,  3,  the  nymphse;  4,  prseputium 
clitoridis ;  5,  frenulum  clitoridis;  6,  frenulum  nympharum ;  7,  hymen;  8,  orifice  of  the 
glands  of  Duverney  ;  9,  tuberculum  vaginre  ;  10,  meatus  urethrse.  (Luschka.) 


labia  majora,  which,  like  the  mons  Veneris,  are  covered,  though  to  a 
less  extent,  with  hair.  In  healthy  young  women  they  are  firm  and 
full,  while  in  deteriorated  constitutions,  and  in  advanced  life,  they 
become  wrinkled  and  pendulous,  from  diminution  of  the  adipose 
tissue. 

The  labia  majora  act  as  a  sort  of  valve,  which  closes  the  orifice  of 
the  vagina,  whence  the  term  vulva — i.  e.,  valva,  the  folding-door  of 
the  ancients.  When  the  labia  are  full  and  well  rounded,  they  are  ap- 
proximated closely  together,  and  form  the  vulva  connivens.    With  the 


FEMALE  ORGANS  OF  GEXERATION. 


3 


loss  of  adipose  tissue,  a  gaping  of  the  flaccid  labia  ensues,  and  forms 
the  vulva  Mans. 

The  labia  olTer  an  external  and  internal  surface.  The  outer  sur- 
face presents  the  usual  characteristics  of  tegumentary  tissue,  and  is 
abundantly  supplied  with  large  sebaceous  glands.  The  inner  surface 
is  in  all  respects  like  a  mucous  membrane,  except  that  it  possesses 
sebaceous  glands  in  place  of  mucous  follicles.  The  subcutaneous  tis- 
sue is  composed  of  connective  tissue,  rich  in  elastic  elements,  and  con- 
taining fatty  lobules  continuous  with  the  underlying  adipose  struct- 
ure. It  furnishes  support  to  an  abundant  venous  plexus,  to  which 
the  turgescence  of  the  labia  i7i  pruritiiy  and  under  sexual  excitement, 
is  mainly  due.  The  existence  of  contractile  elements  has  never  been 
demonstrated. 

The  two  extremities  of  the  vulva  have  been  designated,  respec- 
tively, the  anterior  and  posterior  commissures  of  the  labia  ;  but  these 
terms,  so  far  as  they  convey  the  idea 
of  connecting  bands  between  the  la- 
bia, are  incorrect,  for  Luschka*has 
shown  that  the  labia  are  directly  con- 
tinuous with  the  mons  Veneris  in. 
front  and  the  perinaeum  behind. 

The  clitoris  is  a  small,  elongated 
body,  situated  just  beneath  the  so- 
called  anterior  commissure.  It  re- 
sembles the  penis  in  form  and  struct- 
ure, but  differs  in  possessing  neither 
corpus  spongiosum  nor  urethra.  The 
clitoris  is  divided  into  the  crura,  the 
corpus,  and  the  glans.  The  crura 
are  long,  spindle-shaped  processes,  at- 
tached to  the  borders  of  the  ascend- 
ing rami  of  the  ischia  and  the  de- 
scending rami  of  the  pubis.  The  cor- 
pus is  formed  by  the  junction  of  the 
crura  in  the  median  line,  just  beneath 
the  pubic  arch.  Even  in  a  state  of 
extreme  erection,  it  does  not  normally 
exceed  an  inch  in  length.  The  glans 
is  the  rounded,  imperforate  extremity, 
dimensions  of  a  small  pea. 


Fig.  2. — Lateral  view  of  the  erectile  struct- 
ures of  the  external  orjxans  of  the  fe- 
male (from  Kobelt),  two  thirds.  The 
blood-vessels  have  been  injected,  and 
the  skin  and  mucous  membrane  have 
been  removed,  a,  bulbus  vestibuli ; 
c,  plexus  of  veins,  named  the  pars  in- 
termedia •  e,  glans  clitoridis ;  /,  cor- 
pus clitoridis  ;  7i,  dorsal  vein  ;  7,  right 
crus  clitoridis:  w,  vestibulum ;  ' 
right  gland  of  Bartholin  or  Duverney. 


During  erection  it  attains  the 
The  cuticular  covering  of  the  glans  is  of 
a  pale-red  color,  and  is  covered  with  papillae,  part  of  which  contain 
vessels,  and  part,  nerve-endings  similar  to  those  found  in  the  nipple, 
and  termed  by  Krause  ''terminal  bulbs"  {End-Kolben).    The  nerves 


*  LuscHKA,  "  Die  Anatomie  des  menschlichen  Bcckens,"  p.  407. 


4 


PHYSIOLOGICAL  ANATOMY. 


of  the  clitoris  are  more  fully  developed  than  the  corresponding  nerves 
in  the  penis.  The  clitoris  is  regarded  as  the  seat  of  the  voluptuous 
sensations  experienced  by  the  female  during  copulation. 

The  labia  minora  are  two  narrow,  reddish,  moist  folds  of  mucous 
membrane,  situated  between  the  labia  majora,  with  which  they  are 
continuous  by  their  outer  surface.  The  inner  surface  is  continuous 
with  the  mucous  membrane  of  the  vestibulum.  Tliey  are,  sometimes, 
termed  likewise  the  nymplim.  Nymplice  vocantur  vel  quod  sint  casti- 
tatis  prcBsides,  vel  quod  sponsum  primo  intermittant,  vel  quod  aquis 
prosilientihus  prwsint  (Plazzonus),*  or,  as  Sir  Charles  Bell  words  it 
in  his  Anatomy,"  "The  most  modest  of  the  uses  ascribed  to  them 
is  that  of  directing  the  stream  of  urine.*'  When  the  rima  pudendi  is 
narrow,  as  in  virgins,  the  labia  minora  are  concealed  and  protected  by 
the  labia  majora.  In  the  vulva  hians,  the  labia  minora  acquire,  from 
exposure  to  the  atmosphere,  a  dirty-bluish  color,  and  take  on  the  prop- 
erties of  the  cutis.  In  Hottentot  and  Bushman  women,  they  some- 
times reach  the  length  of  eight  inches,  and  constitute  the  so-called 
"  Hottentot  apron." 

Each  labium  minus  splits  anteriorly  into  two  folds,  of  which  the 
outer  joins  the  corresponding  one  of  the  opposite  side  to  form  a  cover 
for  the  clitoris,  the  prmputium  cUtoridis.  The  lower  folds  converge 
to  meet  beneath  the  lower  border  of  the  glans  clitoridis,  and  form  the 
frenulum  of  the  clitoris.  This  attachment  serves  to  bring  the  clitoris 
forward  into  contact  with  the  penis,  as  the  labia  minora  are  pressed 
inward  during  copulation. 

The  labia  minora  meet  posteriorly,  in  most  instances,  and  form  a 
thin  circular  band,  the  frenulum  vulvce  or  fourcliette.  The  f ourchette 
has  usually  been  regarded  as  the  posterior  commissure  of  the  labia 
majora,  but  this  view  Luschka  has  shown  to  be  incorrect,  f 

The  vestihulum  is  the  angular  space  bounded  by  the  labia  minora 
and  the  vaginal  orifice. 

The  hulhi  vestibuli  vagince,  the  bulbs  of  the  vaginal  vestibule,  are 
two  curved,  leech-shaped  masses  of  reticulated  veins,  situated  between 
the  vestibulum  and  pubic  arch  of  each  side.  Kobelt  has  shown  that 
they  correspond  to  the  two  separated  halves  of  the  male  bulbus  ure- 
thrse.  They  are  composed  of  erectile  tissue,  and  measure,  when  dis- 
tended with  blood,  a  little  over  an  inch  in  length.  As  the  head  of  the 
child  passes  through  the  vulva  during  parturition,  these  bodies  are 
pushed  forward  to  prevent  their  being  compressed  between  the  head 
and  the  pubic  arch.  Still,  rupture  does  sometimes  occur,  and  then 
the  hgemorrhage  leads  to  the  formation  of  thrombus  of  the  labia  ma- 
jora. The  upper  ends  of  the  vaginal  bulbs  are  rather  pointed,  and 
communicate,  by  means  of  a  small  plexus,  the  pars  intermedia  of 

*  LusciiKA,  "  Die  Anatomic  des  menschlichcn  Beckens,"  Tubingen,  1864,  p.  403. 
f  Ibid.,  p.  404. 


FEMALE  ORGANS  OF  GENERATION. 


5 


Kobelt,  with  tlie  vessels  of  the  glans  clitoriclis.  Through  this  connec- 
tion the  blood  is  pressed,  during  venereal  excitement,  by  the  reflex 


Fig.  3. — Front  view  of  the  erectile  structures  of  the  external  organs  of  the  female  (Kobelt). 
A,  pubis  ;  B,  B,  iscliiura  ;  C,  clitoris  ;  D,  .^land  of  the  clitoris  ;  E,  bulb  ;  F,  constrictor 
muscle  of  the  vulva ;  G,  left  pillar  of  the  clitoris  ;  H,  dorsal  vein  of  the  clitoris  ;  I,  inter- 
mediarv  plexus  ;  J,  vein  of  communication  with  the  obturator  vein  ;  K,  obturator  vein  ; 
M,  labia  minora. 

contractions  of  the  musculus  constrictor  cunni,  from  the  turgid 
bulbs  into  the  glans  of  the  clitoris. 

The  ^neatus  urethrce  is  situated  in  the  median  line,  at  the  lower 
portion  of  the  vestibular  space,  about  three  quarters  of  an  inch  from 
the  glans  of  the  clitoris.  It  is  surrounded  by  a  ring  of  muscular  fibers, 
which  keep  it  closed  under  ordinary  circumstances.  These  fibers  cause 
a  puckering  of  the  mucous  membrane,  which  is  easily  recognized  by 
the  experienced  finger,  and  serves  as  a  guide  for  the  introduction  of 
the  catheter. 

Sebaceous  glands  are  found  in  great  abundance  in  the  tissues  of 
the  nymphae,  where  they  furnish  a  fatty,  yellowish- white  material, 
possessing  a  peculiar  odor.  This  material,  when  accumulated  beneath 
the  prepuce  of  the  clitoris,  constitutes  the  smegma  prmjmtii,  so  com- 
mon in  women  who  neglect  the  niceties  of  the  toilet. 

The  mucous  glands  of  the  vulva  are  divided  into  the  glandulse  ves- 
tibulares  majores  and  the  glandulae  vestibulares  minores. 

The  glandules  vestihulares  minores  are  from  five  to  seven  in  num- 
ber, and  are  irregularly  distributed  in  the  neighborhood  of  the  meatus 
urethrae.  They  are  of  the  compound  racemose  variety,  of  about  the 
size  of  poppy-seed,  and  possess  short,  wide  ducts  with  large  orifices. 
Tyler  Smith  says  that  one  of  these  lacunae  may  be  enlarged  suf- 
ficiently to  admit  a  small-sized  catheter,  leading  the  operator  to 


6 


PHYSIOLOGICAL  ANATOMY. 


suppose  that  he  has  reached  the  bladder,  while  the  instrument  is  really 
in  a  cul-de-sac.^ 

The  glandulm  vestibulares  majores  were  first  discovered  in  the 
human  subject  by  Bartholin,  and  bear  sometimes  his  name  and  some- 
times that  of  Duverney.  They  are  two  in  number,  of  the  size  of  a 
pea,  and  of  a  reddish-yellow  color.  They  are  situated  behind  the  pos- 
terior extremities  of  the  bulbi  vestibuli,  which,  however,  they  partially 
overlap.  They  are  of  the  compound  racemose  variety,  and  their  acini 
open  into  a  duct  a  little  over  a  half-inch  in  length,  wide  at  its  begin- 
ning, but  which  narrows  toward  its  orifice.  The  duct  takes  an  oblique 
course  along  the  inner  side  of  the  vaginal  bulbs,  and  terminates  in 
front  of  the  hymen,  at  the  angle  which  the  hymen  or  its  remains  (the 
carunculge  myrtiformes)  makes  with  the  walls  of  the  vestibule.  The 
glands  of  Bartholin  secrete  a  yellowish,  adhesive  fluid,  which  is  poured 
out  freely  during  coitus,  and  preparatory  to  the  passage  of  the  child 
at  the  time  of  labor.  This  secretion,  by  rendering  the  parts  moist 
and  slippery,  serves  to  protect  the  mucous  surfaces  from  mechanical 
injury.  An  abundant  secretion  may  likewise  be  caused  by  erotic 
dreams,  or,  in  fact,  by  any  form  of  sexual  excitement.  They  are 
more  developed  in  young  persons  than  in  those  of  middle  life,  and  in 
eld  age  they  seem  in  some  cases  to  disappear  altogether. 

The  orificium  vaginm  is  bounded  by  the  labia  minora  and  the  ves- 
tibule. It  differs  greatly,  both  as  to  size  and  appearance,  in  young 
children,  in  virgins,  in  women  accustomed  to  sexual  intercourse,  and 
in  those  who  have  borne  children. 

In  virgins,  the  vaginal  orifice  is  partially  closed  by  a  thin  fold  of 
mucous  membrane,  termed  the  hymen.  This  fold  has  usually  a 
crescentic  shape,  with  its  concave  border  looking  toward  the  urethral 
orifice,  so  that  a  small  opening  is  left  anteriorly  for  the  escape  of  the 
menstrual  fluid.  There  are,  however,  a  number  of  other  less  common 
varieties,  of  which  the  following  are  the  most  important :  1.  The 
hymen  annularis,  with  a  small  central  opening.  2.  The  hymen  cribri- 
formis,  with  a  number  of  small  openings.  3.  The  hymen  imperfora- 
tus, which  completely  occludes  the  vagina,  and  occasions  retention  of 
the  menses.  4.  The  hymen  fimbriatus,  from  its  resemblance  to  the 
fringed  extremity  of  a  Fallopian  tube.  This  variety  possesses  med- 
ico-le^al  importance,  from  the  possibility  of  its  being  mistaken  for  a 
normal  ruptured  hymen. 

The  thin  tissues  which  constitute  the  hymen  are  usually  lacerated 
by  the  first  complete  coitus.  Laceration,  however,  is  not,  in  all  cases, 
the  necessary  result  of  sexual  intercourse.  There  is  a  young  girl, 
nineteen  years  of  age,  now  under  treatment  for  amenorrhoea  in  the 
uterine  wards  of  the  Bellevue  Hospital,  who  possesses  a  perfect  hymen, 
the  opening  of  which  is  of  the  ordinary  size,  yet  so  distensible  is  its 

*  W.  Tyler  Smith,  "  Manual  of  Obstetrics,"  p.  22. 


FEMALE  ORGANS  OF  GENERATION. 


7 


tissue  that  a  medium-sized  (one  inch)  Fergusson  speculum  has  been 
repeatedly  introduced,  for  purposes  of  exj)io?rttioft3-  without  in  the 
slightest  degree  affecting  its  integrity.  Hyrtl  mentions  a  specimen  of 
the  female  genitalia  preserved  in  Meckel's  museum,  at  Halle,  where 
the  hymen  is  perfect,  though  the  woman  had  given  birth  to  a  seven- 
months  child.* 

We  are  indebted  to  Schroeder  for  having  pointed  out  that  the  fleshy 
eminences,  known  as  the  caruncul^  myrtiformes,  are  the  result  of 
child-bearing,  and  not,  in  the  rule  at  least,  of  sexual  intercourse. 
Coitus  simply  causes  a  solution  in  the  continuity,  at  one  or  more 
points,  of  the  free  border  of  the  hymen.  The  pressure  of  the  child's 
head,  however,  during  labor  causes  necrosis  and  sloughing  of  the 
heretofore  persistent  though  lacerated  hymen,  of  which,  subsequently, 
the  familiar,  isolated  elevations  of  mucous  tissue  about  the  vaginal 
orifice  famish  the  only  visible  traces,  f  My  own  experience  is  entirely 
confirmatory  upon  this  point.  In  the  examination  of  young  nullipa- 
rous  prostitutes,  who  enter  the  Bellevue  Hospital  for  uterine  disorders, 
I  have  always  found  a  torn  hymen,  but,  in  no  case,  carunculae  myrti- 
formes. 

The  Vagina. — The  vagina  is  a  membranous  canal,  connecting  the 
uterus  with  the  external  parts  of  generation.  It  runs  in  an  oblique 
direction  forward  from  its  attachment  at  the  cervix  to  its  orifice  at  the 
vulva.  When  not  artificially  dilated,  its  anterior  and  posterior  walls 
are  in  contact  with  each  other.  The  length  of  the  vagina,  owing  to  its 
extraordinary  distensibility,  is  usually  greatly  over-estimated.  Admit- 
ting considerable  variations,  dependent  upon  weight,  position,  etc.,  of 
the  uterus,  two  and  a  half  inches  for  the  anterior,  and  a  little  over 
three  inches  for  the  posterior  wall  may  be  accepted  as  fair  average 
measurements.  I  The  vagina  is  placed  between  the  rectum  and  bladder, 
and  is  more  or  less  intimately  connected  with  both  those  organs.  In 
its  upper  fifth,  the  vagina  is  separated  from  the  rectum  by  the  cul-de- 
sac  of  Douglas.  From  thence  downward,  the  rectum  and  vagina  form 
a  common  partition,  the  septum  recto-vaginale.  Above  the  pelvic 
floor,  a  layer  of  connective  tissue  continuous  with  the  pelvic  fascia 
unites  the  rectum  and  vagina  together.  Below  the  pelvic  floor  the 
union  of  the  two  organs  is  immediate.  Luschka  limits  the  term 
septum  recto-vaginale"  to  this  lower  half  of  the  common  Avail.* 
The  upper  half  of  the  anterior  vaginal  wall  is  attached  to  the  blad- 
der by  means  of  loose  connective  tissue,  while  the  lower  half  is  insepa- 
rable from  the  tissues  about  the  urethra.  The  partition  thus  formed 
between  the  urethra  and  vagina  is  termed  the  septum  urethro-vaginale. 

*  Hyrtl,  "Hand  buchder  topographischen  Anatomie,"  Wicn,  5te  Auflage,  Bd.  ii,  p.  162. 
f  ScHROKDER,  "  Schwangerschaft,  Geburt,  und  Wochenbett,"  Bonn,  186Y,  p.  6. 

X  LusciiKA,  "Die  Anatomic  des  menschlichen  Bcckens,"  Tubingen,  1864,  p.  383. 

#  /bid.,  p.  384. 


8 


PHYSIOLOGICAL  ANATOMY. 


The  fornix,  as  the  upper  part  of  the  vagina  is  termed,  encircles 
the  vaginal  portion  of  the  cervix  in  such  a  way  as  to  extend  at  least 
twice  as  high  upon  its  posterior  as  upon  its  anterior  aspect.  The 
vaginal  walls,  when  not  distended  artificially,  are  directly  applied 
to  the  vaginal  portion  of  the  cervix. 


Fig.  4. — Section  through  the  female  pelvis,  1,  rectum ;  2,  uterus ;  3,  excavatio  recto-ute- 
rina  (cul-de-sac  of  Douglas)  5  4,  excavatio  vesico-uterina ;  5,  bladder;  6j  clitoris ;  7j  ure- 
thra ;  8,  symphysis  ;  9^  sphincter  ani ;  10,  vagina.  (Kohlrausch  modified  by  Spiegel- 
berg.) 

The  structure  of  the  vaginal  walls  is  not  identical  in  all  parts  of  the 
canal.  In  the  upper  portion  the  internal  surface  is  nearly  smooth,  and 
the  walls  measure  from  a  half  a  line  to  a  line  in  thickness.  They  are 
composed  of  a  mucous  membrane,  a  muscular  coat,  and  an  external 
connective-tissue  sheath,  or  layer.  The  latter  is  highly  elastic,  and 
affords  support  to  the  vaginal  blood-vessels.  The  muscular  fibers, 
which  are  of  the  involuntary  variety,  run  in  both  a  longitudinal  s,^d 


FEMALE  ORGANS  OF  GENERATION. 


9 


transverse  direction,  and  are  so  interwoven  together  that  a  dissection 
into  distinct  strata  is  impossible. 

The  connective-tissue  and  muscular  layers  gradually  increase  in 
thickness  as  they  approach  the  vaginal  orifice.  A  circular  bundle  of 
voluntary  fibers,  the  si^liincter  vagince  of  Luschka,  surrounds  the  lower 
extremity  of  the  vagina  and  urethra.  The  contraction  of  this  sphinc- 
ter not  only  acts  upon  the  vaginal  orifice,  but  likewise  serves  to  close 
the  urethra  by  compressing  it  against  the  septum  urethro-vaginale.* 

The  vaginal  columns  are  two  thickened  ridges,  which  occur  in  the 
median  line,  upon  the  anterior  and  pos- 
terior walls,  at  the  lower  portion  of  the 
vagina.  The  anterior  column  is  more 
prominent,  in  the  rule,  than  the  poste- 
rior. It  is  often  divided  into  two  por- 
tions by  a  longitudinal  furrow.  In  these 
thickened  ridges  the  muscular  fibers  pos- 
sess a  trabecular  arrangement  and  inclose 
offshoots  from  the  venous  plexus.  The 
columns  thus  present  a  cavernous  struct- 
ure. They  are  not,  however,  endowed 
with  erectility.  When  turgid  with  blood, 
they  serve  to  close  the  vagina,  but  the 
resistance  they  offer,  like  that  afforded 
by  a  filled  sponge,  is  easily  overcome.  \ 
The  mucous  membrane  covering  the  col- 
umns is  greatly  thickened,  and  abun- 
dantly supplied  with  vessels. 

The  vagina  is  likewise  furnished  with 
transverse  ridges  (cristce,  not  rugm — they 
are  not  wrinkles),  which  are  more  fully 
developed  upon  the  anterior  than  upon 
the  posterior  wall.  In  virgins  these 
ridges  possess  a  nearly  cartilaginous  con- 
sistence. Any  relaxing  agency,  such  as 
chronic  catarrh,  child-bearing,  and  the 
like,  serves  to  efface  them,  and  render 
the  vagina  smooth. 

The  mucous  membrane  of  the  vagina 
is  covered  with  numerous  vascular  pa- 
pillae, which,  under  certain  conditions,  es- 
pecially those  pertaining  to  pregnancy,  may  reach  such  a  degree  of  devel- 
opment as  to  communicate  to  the  finger  a  distinctly  granular  sensation. 

*  Luschka,  "Die  Anatomie  des  menschlichen  Beckens,"  Tubingen,  1864,  p.  38Y. 

f  Henle,  "  Handbuch  der  Eingeweidelehre  des  Menschen,"  Braunschweig,  18G6,  p. 


Fig.  5. — The  vagina  (exposed  in  its 
entire  length  by  the  removal  of 
the  posterior  wall).  Ou^  orifici- 
um  urethrae  ;  Oue^  orificium  ute- 
rinum-externura ;  section  of 
wall  at  the  fornix  vaginae.  (Hen- 
le.) 


FEMALE  ORGANS  OF  GENERATION. 


11 


Though  there  are  no  secreting  glands,  the  vagina  is  covered,  even 
in  periods  of  repose,  with  a  thin  layer  of  acid  mucus.  Under  sexual 
excitement,  and  during  menstruation  or  pregnancy,  the  amount  of 
this  secretion  is  largely  increased. 

The  hypogastric,  the  uterine,  the  vesical,  and  the  pudendal  arteries 
all  send  branches  to  the  vagina.  The  pulsations  of  the  uterine  artery 
may  sometimes  be  felt  through  the  upper  part  of  the  vaginal  walls. 
During  pregnancy  these  pulsations  are  always  so  distinctly  marked  as 
to  constitute  a  good  inferential  sign  of  that  condition. 

The  veins  form  a  close  plexus  around  the  vagina.  Like  all  the 
pelvic  veins,  they  are  without  valves,  and  are  therefore  peculiarly  sub- 
ject to  stasis  from  anything  that  interferes  with  the  return  circula- 
tion. Blood-stasis,  with  enlargement  of  the  vaginal  veins,  communi- 
cates a  deep-purple  color  to  the  vagina.  As  the  requisite  conditions 
are  fulfilled  during  gestation,  Jacquemin  and  Kluge  proposed  to  in- 
clude this  coloration  of  the  Vagina,  which  they  compared  to  wine-lees, 
among  the  signs  of  pregnancy.  It  occurs,  however,  though  perhaps 
to  a  less  intense  degree,  in  prolapsus  uteri,  in  cases  of  pelvic  tumors, 
and  the  like.  As  free  interaommunication  exists  between  the  vaginal 
plexus  and  the  plexuses  distributed  to  the  pudendum,  the  rectum, 
the  bladder,  and  the  uterus,  a  disturbance  in  the  circulation  of  any 
one  of  these  organs  is  necessarily  attended  with  some  degree  of  circu- 
latory disturbance  in  all  the  contiguous  organs. 

The  general  relations  of  the  external  and  internal  organs  of  genera- 
tion are  admirably  given  in  Fig.  6,  which  we  have  borrowed  from  Beigel.* 
It  represents  the  complete  generative  system  of  a  virgin  (natural  size). 

II.  The  Uterus,  Fallopian  Tubes,  and  Ovaries. 

The  Uterus. — The  uterus  in  the  virgin  differs  somewhat  in  shape 
and  size  from  that  of  a  woman  who  has  borne  children.  The  following 
description  is  intended  to  apply  to  the  nulliparous  uterus  only:  In 
outward  form  the  uterus  has  been  compared  to  an  inverted,  wide- 
necked  flask.  It  is  flattened  antero-posteriorly.  Its  average  length 
is  in  the  neighborhood  of  two  and  a  half  inches,  though  its  dimensions 
vary  to  a  very  considerable  extent.  It  is  divided  by  a  tolerably  well- 
defined  constriction  into  two  parts  of  nearly  equal  length.  The  upper, 
larger  portion  possesses  an  anterior,  flattened,  and  a  posterior,  convex 
surface.  It  is  limited  by  three  borders.  The  upper  border  is  moder- 
ately convex.  The  lateral  borders  are  convex  above  and  concave  be- 
low. The  Fallopian  tubes  pass  into  the  uterus  at  the  junction  of  the 
upper  and  lateral  borders.  The  width  of  the  uterus  at  this  point  is 
about  one  inch  and  a  half.  The  lower  portion  has  a  spindle  shape, 
and  measures  about  a  half-inch  in  its  widest  diameter. 


*  Beigel,  "Die  Krankheiten  des  vveiblichen  Gcschlcclites,"  Erlangen,  18*74,  Bd.  i,  p. 
hg.  2. 


12 


PHYSIOLOGICAL  ANATOMY. 


All  the  lower,  spindle-shaped  portion  of  the  uterus  is  termed  the 
cervix,  or  neck.  The  portion  of  the  uterus  comprised  between  the 
neck  and  the  Fallopian  tubes  is  called  the  corpus  or  body.  The 
segment  situated  above  the  Fallopian  tubes  is  distinguished  as  the 
fundus.  r^ 


Fig.  7. — Virgin  uterus.  A,  anterior  view ;  B,  median  section  ;  C,  transverse  section  (Sap- 
j)ey).  A,  1,  body;  2,  2,  ancfles ;  3,  cervix;  4,  site  of  the  os  internum;  5,  vaginal  por- 
tion of  the  cervix;  6,  external  os ;  7,  7,  vagina.  B,  1,  1,  profile  of  the  anterior  surface; 
2,  vesico-uterine  cul-de-sac ;  3,  3,  profile  of  the  posterior  surface  ;  4,  body  ;  5,  neck  ;  6, 
isthmus ;  7,  cavity  of  the  body  ;  8,  cavity  of  the  cervix ;  9,  os  internum ;  10,  anterior 
lip  of  the  OS  externum  ;  11,  posterior  lip  ;  12,  12,  vagina.  C,  1,  cavity  of  the  body  ; 
2,  lateral  wall ;  3,  superior  wall ;  4,  4,  cornua ;  5,  os  internum ;  6,  cavity  of  the  cervix ; 
7,  arbor  vitye  of  the  cervix ;  8,  os  externum  ;  9,  9,  vagina. 

The  lower  extremity  of  the  cervix  projects  freely  into  the  vagina, 
and  forms  the  portio  vaginalis,  the  vaginal  portion.  It  possesses  a 
transverse  aperture,  measuring  from  a  half  a  line  to  two  lines  in  width, 
termed  the  external  orifice,  or  more  frequently  the  os  tinccB,  from  a 
fancy  of  the  anatomists  that  it  resembled  the  mouth  of  a  tench.  The 
OS  tincse  is  bounded  by  two  thick  lips,  of  which  the  anterior  is  abso- 
lutely longer  than  the  posterior.  As,  however,  the  distance  from  the 
external  orifice  to  the  vaginal  insertion  is  about  half  as  great  anteriorly 
as  posteriorly,  a  sensation  is  communicated  to  the  finger,  when  an 
examination  is  made  per  vaginam,  as  though  the  anterior  lip  were 
really  the  shorter  of  the  two.  This  absolute  superior  length  of  the 
anterior  lip,  combined  with  the  natural  oblique  direction  of  the  uterus, 
causes  the  external  orifice  to  look  nearly  directly  backward,  a  fact 
which  is  readily  recognized  when  the  organs  are  examined  in  situ  by 
means  of  a  Sims's  speculum. 

Upon  lateral  section,  the  uterus  is  found  to  be  provided  with  a 
cavity,  in  which  the  upper  portion  or  cavity  of  the  body  is  to  be  dis- 
tinguished from  the  lower  portion  or  canal  of  the  cervix.  The  cavity 
of  the  tody  presents  a  triangular  shape  with  convex  borders.    The  ^wo 


i 


FEMALE  ORGANS  OF  GENERATION. 


13 


upper  angles  communicate  by  a  small  opening,  hardly  large  enough  to 
admit  a  fine  bristle,  with  the  canal  of  the  Fallopian  tubes.  At  the 
lower  angle  is  situated  the  os  internum,  a  circular  orifice,  large  enough 
to  admit  a  uterine  sound,  which  forms  the  internal  anatomical  limit 
between  the  body  and  the  cervix.    The  canal  of  the  cervix  has  a  fusi- 


Fio.  8. — Virgin  uterus  opened  posteriorly,  showinir  at  A,  J,  the  os  internum ;  ai  0    os  exter- 
num ;  P,  peritoneal  folds.  (Bandl.) 

form  shape,  and  is  included  between  the  internal  and  external  orifices 
already  described.  Its  inner  surface  is  characterized  by  two  longitu- 
dinal ridges,  occupying  the  anterior  and  posterior  walls,  from  which 
branching  processes  extend  obliquely  upward,  giving  rise  to  an  appear- 
ance which  justifies  the  title — arbor  vitce  uterina. 

In  women  who  have  borne  children,  the  uterus  measures  three  inches 
in  length,  of  which  nearly  two  inches  belong  to  the  body  and  one  to 
the  cervix.  There  is  increased  convexity  of  the  fundus.  The  distance 
between  the  insertions  of  the  Fallopian  tubes  measures  over  two  inches. 
The  width  of  the  cervix,  at  its  junction  with  the  body,  measures  one 
inch.  The  uterus  thus  assumes  a  pyriform  shape.  The  cavity  of  the 
uterus  loses  its  triangular  character,  and  assumes  a  more  ovoid  ap- 
pearance. The  external  orifice  no  longer  forms  a  smooth  transverse 
depression,  but  its  edges,  lacerated  by  childbirth,  communicate  the 
impression  of  a  rounded,  puckered  surface. 

When  a  profile  section  is  made  through  a  perfectly  healthy  unim- 
pregnated  uterus,  its  walls  are  found  in  actual  contact.  A  cavity  does 
not,  therefore,  naturally  exist. 

The  uterus  is  so  situated  in  the  pelvic  cavity  as  to  possess  a  large 


14 


PHYSIOLOGICAL  ANATOMY. 


degree  of  mobility.  Its  lower  extremity  projects,  as  we  have  seen, 
into  the  vagina.  The  supra-vaginal  portion  of  the  cervix  is  attached 
anteriorly  to  the  walls  of  the  bladder.  That  portion  of  the  uterus 
which  extends  freely  into  the  pelvic  cavity  is  covered  by  a  reflection 
of  the  peritonaeum,  precisely  as  though  the  uterus  had  been  pushed 
from  below  upward  into  the  peritoneal  sac.  Thus  the  peritonaeum 
covers  the  uterus  anteriorly  and  posteriorly.  Its  two  surfaces  meet  at 
the  lateral  borders  of  the  uterus,  and  thence  spread  outward  to  the 
ilia  of  the  respective  sides.  These  peritoneal  folds  divide  the  pelvic 
cavity  into  two  nearly  equal  halves,  and  are  termed  the  ligamenta  lata, 
or  broad  ligaments. 

Two  peritoneal  folds,  containing  a  few  contractile  fibers  derived 
from  the  muscular  tissue  of  the  uterus,  pass  forward  from  the  uterus 
to  the  bladder — the  pliccB  vesico-uterince.  These  folds  form  the  sides 
to  a  space,  limited  anteriorly  and  posteriorly  by  the  bladder  and  uterus, 
termed  the  excavatio  vesico-uterina.   (  Vide  Fig.  4,  p.  8.) 

Upon  the  posterior  surface,  the  peritonaeum  descends  down  not 
only  over  the  entire  supra- vaginal  portion  of  the  uterus,  but  over  that 
portion  of  the  vagina  which  covers  the  posterior  lip  of  the  infra-vagi- 
nal portion.    Thence  it  curves  upward,  and  becomes  continuous  with 


Fig.  9. — Uterus  of  a  woman  who  has  borne  children.  the  portion  of  the  uterine  cavity 

corresponding  to  the  peritoneal  folds,  P,'  i>,  B\  os  internum ;  0  e,os  externum.  (Bandl.) 


the  peritoneal  investment  of  the  rectum.  Thus  a  deep  cul-de-sac  is 
formed  between  the  uterus  and  the  rectum,  known  as  the  excavatio 
recto-uterina,  or  cul-de-sac  of  Douglas.     Two  lateral  folds  of  peri- 


FEMALE  ORGANS  OF  GENERATION. 


15 


tonseum  likewise  pass  from  the  uterus  to  the  rectum,  which  form  sides 
to  this  space,  the  pUcm  recto-utermce.  These  folds  inclose  in  their 
free  borders  contractile  muscular  fibers,  derived  from  the  uterus  and 
vagina.  The  plicae  recto-uterin^e  pass  backward,  near  tlie  rectum,  to 
the  neighborhood  of  the  second  sacral  vertebra.  As  the  muscular 
fibers  they  contain  fulfill  the  function  of  maintaining  the  uterus  in  a 
state  of  normal  anteversion,  Luschka  proposes  that  they  should  be 
termed  the  retractores  uteri.* 

The  peritonaeum  covering  the  uterus  is  an  exceedingly  delicate 
membrane.  In  front  it  is  so  adherent  to  the  subjacent  tissues  that  it 
can  not  be  removed  by  dissection  without  tearing.  Behind,  on  the 
contrary,  it  is  connected  with  the  uterus  by  a  loose  areolar  tissue,  and 
can  be  easily  stripped  up  by  the  finger.  On  this  account  inflamma- 
tory processes  are  attended  with  more  pain  when  situated  anteriorly 
than  posteriorly. 

Though  it  may  be  proper  to  speak,  in  a  general  way,  of  the  uterus 
as  occupying  a  position  coincident  with  the  axis  of  the  superior  pelvic 
strait,  it  must  be  borne  in  mind  that,  in  reality,  its  position  is  largely 
influenced  by  the  neighboring  organs.  Thus,  a  full  bladder  pushes 
the  fundus  backward.  A  full  rectum  shoves  the  cervix  forward. 
When  bladder  and  rectum  are  both  evacuated,  the  action  of  the  re- 
tractor muscles  in  the  recto-uterine  folds  produces  a  limited  amount 
of  anteversion. 

The  uterus  is  composed  of  muscular  fibers  of  the  un  striped  variety, 
arranged  in  bundles  and  united  together  by  delicate  processes  of  con- 
nective tissue.  The  arrangement  of  these  muscular  fibers  has  been 
chiefly  studied  in  advanced  pregnancy,  when  three  separate  layers  may 
be  readily  distinguished  : 

1.  The  superficial  layer,  which  covers  the  anterior  and  posterior 
surfaces  of  the  uterus  like  a  hood,  while  the  sides  are  left  free.  It 
possesses  a  membranous  thinness,  and  is  intimately  adherent  to  the 
peritonaeum.  It  furnishes  longitudinal  fibers  to  the  external  muscular 
layer  of  the  Fallopian  tubes.  From  the  posterior  surface  its  fibers 
converge  to  form  the  Ugamentum  ovarii,  a  broad  band,  measuring 
about  an  inch  in  length  and  a  fifth  of  an  inch  in  width,  which  passes 
from  the  upper  lateral  portion  of  the  uterus,  between  the  layers  of  the 
broad  ligament,  to  the  ovary.  From  the  anterior  surface  a  similar 
bundle  of  a  round  form,  the  Ugamentum  teres,  passes  through  the  in- 
guinal canal  to  the  symphysis  pubis,  where  its  fibers  terminate  in  the 
connective  tissue  of  the  mons  Veneris.  The  ligamentum  teres  is  four 
to  five  inches  in  length,  and,  in  the  unimpregnated  uterus,  when  the 
fundus  is  depressed  below  the  pelvic  brim,  runs  in  a  curved  direction, 
upward,  outward,  and  forward,  to  gain  the  internal  inguinal  ring. 

*  Luschka,  "  Die  Anatomie  des  weiblichen  Beckens,"  Tubingen,  1864,  p.  361.  It  is 
evident  that,  by  drawing  the  cervix  backward,  the  fundus  of  the  uterus  is  thrown  forward. 


16 


PHYSIOLOGICAL  ANATOMY. 


2.  The  median  layer,  which  constitutes  the  great  bulk  of  the 
uterine  walls.  It  is  composed  of  longitudinal  and  transverse  fibers, 
which,  in  place  of  being  arranged  in  distinct  strata,  as  is  the  rule  in 
other  hollow  muscles,  form  an  intricate  interlacement,  in  the  meshes  of 
which  are  contained  the  vessels  of  the  organ.  The  longitudinal  are  in 
part  derived  from  the  lower  transverse  fibers,  and  pass  downward  to  be- 
come continuous  with  the  longitudinal  fibers  of  the  vagina,  and  in  part 
are  longitudinal  from  the  beginning,  but  are  closely  interwoven  with 
the  transverse  fibers.  As  they  descend  to  the  cervix,  they  gradually 
diminish  in  bulk,  and  terminate  by  fine  processes  in  the  connective 
tissue  directly  underlying  the  mucous  membrane  of  the  vaginal  portion. 

3.  The  inner  layer,  composed  of  circular  fibers,  continuous  with 
the  circular  fibers  of  the  Fallopian  tubes  above  and  those  of  the  vagina 
below.  This,  like  the  external  layer,  is  extremely  insignificant  in  size. 
It  represents  the  vestiges  of  the  early  development  of  the  uterus  from 
the  filaments  of  Miiller.  A  special  reenforcement  of  the  muscular  fibers 
around  the  internal  orifice  of  the  cervix,  constituting  the  so-called 

sphincter,"  is  admitted  by  most  anatomists. 

Upon  the  outer  surface  of  the  cervix,  just  at  the  point  of  the  vagi- 
nal attachment,  there  is  a  well-developed  layer  of  transverse  muscular 
fibers.  Circular  vessels,  imbedded  in  a  loose-meshed  connective  tissue 
containing  wide  lymphatic  spaces,  surround  the  cervix  at  the  same 
point.  Thus  a  ridge  is  formed,  which  is  greatly  augmented  in  size 
during  pregnancy. 

In  the  cervix,  the  connective  tissue  exists  in  the  form  of  well-differ- 
entiated fibers  of  the  ordinary  variety.  In  the  body  of  the  uterus,  a 
similar  loose-meshed,  wavy  connective  tissue  is  found  in  the  external 
layer,  where  it  sends  processes  between  the  muscular  bundles,  and  sur- 
rounds the  vessels.  In  the  median  layer,  rings  of  connective  tissue 
accompany  the  vessels,  while  fibers  of  the  finest  description  penetrate 
between  the  muscular  bundles.  Fine  fibers,  of  a  like  character,  but 
more  abundant,  are  found  in  the  inner  muscular  stratum,  whence  they 
pass  directly  into  the  connective  tissue  of  the  mucous  membrane. 

The  mucous  membrane  of  the  uterus  is  divided  into  that  lining  the 
body  and  that  which  lines  the  cervical  portion,  between  which  char- 
acteristic differences  of  structure  exist. 

The  mucous  membrane  of  the  hody  is  smooth  and  soft.  At  the 
fundus  and  upon  the  sides  it  measures  about  -^^  of  an  inch  in  thick- 
ness, but  is  thinner  in  the  vicinity  of  the  tubes  and  the  cervical  por- 
tion. It  is  covered,  under  normal  conditions,  with  a  thin  layer  of 
transparent  alkaline  mucus.  When  examined  with  a  magnifying-glass 
its  surface  presents  a  perforated  appearance,  due  to  the  openings  of  the 
uterine  glands.  These  glands  are  of  the  tubular  variety,  have  a  sinu- 
ous course,  and  are  oftentimes  divided  below  into  two  or  three  separate 
blind  extremities.    They  extend,  in  the  rule,  through  the  entire  thick- 


FEMALE  ORGANS  OF  GENERATION. 


17 


the  mucous  membrane  of 
a  normal  virgin  uterus, 
magnified  about  forty 
diameters  (Kundrat  and 
Engelmann).  *S,  mucous 
membrane  ;  Z>,  glands  ; 
J/,  muscular  tissue  be- 
longing to  the  internal 
layer. 


ness  of  the  mucous  membrane,  and,  in  rare  instances,  penetrate  into 
the  muscular  tissue  of  the  uterus.  They  possess  a  delicate  basement 
membrane,  composed  of  spindle-shaped  cells, 
which  dovetail  into  one  another  like  the  en- 
dothelium of  the  capillaries  and  lymphatics.* 
They  are  lined  by  cylindrical  cells  which  are 
said  to  possess  ciliae.  The  mucous  membrane 
of  the  body  of  the  uterus  possesses  an  e23itheli- 
um  of  the  ciliated  variety,  which  produces  a 
current  in  the  direction  of  the  Fallopian  tubes,  f 

A  very  irregular  capillary  net- work,  with  M^^l^f^p 
delicate  walls,  extends  between  the  glands,  and  Fig.  lo.  — Section  throucrh 
passes  near  the  free  surface  into  venous  radi- 
cles, which  furnish  during  menstruation  the 
source  of  venous  haemorrhage. 

The  intermediate  space  is  filJed  up  by  a 
connective-tissue  mesh-work,  composed  of  fine 
processes  and  spindle-shaped  cells,  whose  nu- 
clei impart  to  hardened  specimens  a  granular 
appearance.  Leopold  J  claims  for  this  mesh- 
work  the  significance  of  lymph-sinuses.  The 
close  attachment  of  the  mucous  membrane  to 
the  muscular  tissue  is  explained  by  the  direct 
continuity  of  the  connective  tissues  of  the  two 
structures. 

The  mucous  membrane  of  the  cervix  is  of  a 
yellowish-red  color,  of  a  firm  consistence,  and 
possesses  the  penniform  ridges  already  described. 
It  is  therefore  readily  distinguished,  both  by 
the  eye  and  the  touch,  from  the  red,  smooth, 
velvety  structure  of  the  mucous  membrane 
lining  the  body.  At  the  time  of  puberty,  it 
possesses  a  ciliated,  cylindrical  epithelium, 
which  extends  down  to  within  from  two  to  three 
lines  of  the  os  externum.*  Simple  gland-tubes, 
and  glands  with  multiple  culs-de-sac,  are  found 
upon  the  crests  and  sides  of  the  ridges  and 
upon  those  portions  of  the  cervical  canal  in 
which  ridges  do  not  exist.  These  glands  are, 
Sre'lJ^i^^  OV'eS"^^^^       genetically  considered,  simple  inversions  of  the 

*  Leopold,  "  Die  Lymphgefasse  des  normalen  nicht  schwangeren  Uterus,"  "  Arch, 
f.  Gynaek.,"  Bd.  vi,  1873,  Ileft  1,  p.  83. 

f  V.  Stricker,  "Die  Lehre  dor  Geweben,"  Leipsic,  1871,  art.  "Uterus,"  von  Dr.  R. 
Chrobak,  pp.  1173  et  seq.  %  ^P-      >  P- 

*  LoTT,  "Zur  Anatomie  und  Physiologic  der  Cervix  Uteri,"  Erlangen,  1872,  p.  17. 


Fig.  11. — Section  through 
uterus  showing  cavity. 


18 


PHYSIOLOGICAL  ANATOMY. 


mucous  membrane,  and  are  lined  by  ciliated  epithelium.  When  the 
neck  of  one  of  these  glands  becomes  obstructed,  the  secretion  accu- 
mulates, and  forms  the  straw-colored  vesicles  which  have  been  termed 
the  ovula  of  Naboth.  Papillary  structures,  of  clavate  shape,  are  very 
numerous  in  the  lower  half  or  third  of  the  canal.  According  to 
Lott,*a  section  through  one  of  these  papillag  is  not  to  be  distinguished 
from  a  section  through  one  of  the  smaller  folds  of  the  arbor  vitae 
uterina.  The  cervical  mucous  membrane  affords  thus  an  extensive 
secretory  surface,  furnishing  an  alkaline  mucus,  which  possesses  im- 
portant physiological  functions  in  connection  with  conception,  preg- 
nancy, and  labor. 

The  Fallopian  Tubes. — The  Fallopian  tubes,  as  the  history  of  their 
developments  goes  to  demonstrate,  are,  strictly  speaking,  integral  por- 
tions of  the  uterus.  A  glance  at  Fig.  13,  p.  19,  will  serve  to  make 
apparent  the  continuity  between  the  tissues  of  the  uterus  and  those 
of  the  Fallopian  tubes.    It  will  be  noticed,  too,  that  the  canal  of  the 


Fig.  12. — Posterior  lateral  view  of  the  uterus  ( U.t.)^  with  portion  of  lig.  latum  (L.I.),  oviduct, 
and  ovary.  6>6?,  isthmus  ;  6>c;^',  ampulla  ;  </,  infundibulum  ;  6*.a.,  ostium  abdominale  ; 
T.O.,  fimbria  ovarica;  0,  ovarium :  Z.o.,  lig.  ovarii;  L.i.o.,  lig.  infundibulo-ovaricum  ; 
Z.i.p.j  lig.  infundibulo-pelvicum ;  Po,  parovarium.  (Henle.) 


latter  communicates  directly  with  the  uterine  cavity.  The  Fallopian 
tubes  measure  from  three  to  four  inches  in  length.  They  are  included 
between  the  folds  of  the  broad  ligament  at  its  upper  border.  As  they 
pass  outward  from  the  uterus  they  follow  a  somewhat  sinuous  course, 
and  gradually  increase  in  width  and  thickness.  The  free  extremity 
possesses  an  opening  communicating  with  the  abdominal  cavity,  the 

*  Loc.  cii.,  p.  20. 


FEMALE  ORGANS  OF  GENERATION. 


19 


ostium  aMominale,  which  is  large  enough  to  admit  a  small  goose- 
quill  (2"),  whereas  the  uterine  opening  does  not  exceed  -^^  of  an 
inch  in  diameter.  Henle  designated  the  inner,  narrower  half, 
which  runs  a  comparatively  straight  course,  the  isthmus,  and  the 
outer,  sinuous,  dilated  portion  the  ampulla  of  the  tube.  A  number 
of  ragged,  fringe  -  like  processes  surround  the  ostium  abdominale, 
whence  the  name  fimbriated  extremity  of  the  tube.  These  fringes 
received  likewise  from  the  mediaeval  anatomists  the  name  morsus 
diaboli  from  a  supposed  resemblance  to  the  root  of  the  scabiosa  suc- 
cissa,  the  peculiar  appearance  of  which  was  ascribed  by  the  super- 
stitious to  a  bite  the  devil  gave  it  in  a  fit  of  anger  at  its  beneficent 
action  in  the  maladies  that  affect  the  human  race.*  One  of  the  fim- 
briae {F.o.)  is  rather  longer  than  the  rest,  and  is  attached  to  the  outer 
angle  of  the  ovary. 

The  muscular  imlls  of  the  tubes  are  composed  of  unstriped  fibers, 
similar  to  those  described  as  existing  in  the  uterus.  They  are  ar- 
ranged in  two  layers  :  one,  longitudinal,  continuous  with  the  external 
layer  of  the  uterus ;  and  the  other,  circular,  continuous  with  the 
circular  fibers  of  the  inner  uterine  layer.  Galvanization  of  the  tubes 
causes  contractions  of  a  vermicular  character. 

Between  the  muscular  walls  and  the  peritoneal  covering  there  is  a 
connective-tissue  layer,  which  gives  support  to  a  rich  plexus  of  blood- 
vessels. 

The  mucous  membrane  of  the  tubes  is  extremely  vascular,  and  has 


Fig.  13.— Section  through  Fallopian  tube. 


a  ciliated  epithelium,  which  produces  a  current  in  the  direction  of 
the  uterus.    It  presents  numerous  longitudinal  folds,  which  are  much 

*  Hyrtl,  "  Topographische  Anatomic,"  Wien,  1865,  Bd.  xi,  p.  210. 


20 


PHYSIOLOGICAL  ANATOMY. 


more  complicated  in  the  ampulla  than  in  the  isthmus.  In  the  ampulla 
these  folds  possess  an  arborescent  character,  as  may  be  seen  in  the  fol- 
lowing figure  : 


f 


Fig.  14, — Section  through  ampulla  (thirty  diameters),  a,  submucous  tissue  •  5,  muscular 
layer  ;  c,  serous  coating  ;  mucous  membrane  ;  e,  vessels  •  1,1,  little  folds,  resembling 
villot;ities  when  seen  in  profile  ;  2,  2,  longitudinal  folds  of  larger  size,  witn  numerous 
accessory  folds ;  3,  3,  little  folds,  united  together  so  as  to  form  a  sort  of  canalicular  net- 
work. (Luschka.) 

The  Ovaries. — The  ovaries  are  two  flattened,  nearly  ovoid  bodies, 
situated,  according  to  the  usual  description,  between  the  layers  of  the 
broad  ligament.  They  measure  from  one  to  one  and  a  half  inch  in 
length,  from  three  fourths  of  an  inch  to  an  inch  in  breadth,  and  from 
a  third  to  a  half  inch  in  thickness.  Each  ovary  is  connected  with  the 
uterus  by  a  muscular  band  about  an  inch  in  length  and  a  fifth  of  an 
inch  in  width,,  termed  the  ligamentum  ovarii. 

Previous  to  puberty  the  ovaries  present  a  smooth  surface,  but  after 
maturity  they  become  uneven  and  corrugated  from  the  enlargement, 
rupture,  and  cicatrization  of  the  Graafian  follicles. 

Although  the  ovaries  are  said  to  be  of  ovoid  shape,  in  reality  one 
border  is  much  more  convex  than  the  other.  The  comparatively 
straight  border  is  attached  to  the  posterior  surface  of  the  anterior 
layer  of  the  broad  ligament.  The  posterior  layer  of  the  broad  liga- 
ment is  apparently  reflected  over  the  entire  ovary,  with  the  exception 
of  the  attached  border,  at  which  point  the  hilum,  or  opening,  is  situ- 
ated, through  which  the  spermatic  vessels,  which  are  included  between 


FEMALE  ORGANS  OF  GENERATION. 


21 


the  folds  of  the  broad  ligament,  find  entrance  into  the  substance  of 
the  organ.  Waldeyer  claims  that  the  peritonaeum  ceases  abruptly  at 
the  base  of  the  ovary.  He  states  that  just  where  the  reflection  is  sup- 
posed to  take  place,  microscopic  sections  show  that  the  epithelium  of 
the  serous  membrane  is  replaced  by  one  possessing  a  cylindrical  char- 
acter. In  accordance  with  this  view,  then,  the  surface  of  the  ovary 
would  have  to  be  classed  with  the  mucous  rather  than  with  the  serous 
membranes,  and  should  be  regarded  as  texturally  in  continuity  rather 
with  the  lining  of  the  Fallopian  tubes  than  with  the  peritongeum.* 

When  the  broad  liga- 
ments are  removed  from 
the  body,  and  held  as  near- 
ly as  possible  in  the  natural 
position,  the  convex  border 
of  the  ovary  looks  down- 
ward. If  the  -  broad  and 
ovarian  ligaments  are,  how- 
ever, put  upon  the  stretch, 
the  convex  border  rises  and 
looks  directly  backward. 

The  ovary  is  found,  upon 
section,  to  contain  a  fibrous 
stroma,  the  arrangement  of 
which  can  be  best  under- 
stood by  reference  to  the 
accompanying  excellent  il- 
lustration from  Henle. 

Externally,  the  ovary  is 
surrounded  by  a  fibrous 
coating,  the  so-called  tuni- 
ca albuginea.  In  the  first 
three  years  of  existence, 
however,  the  albuginea  is 
wanting.  Even  in  a  state 
of  complete  development, 
it  can  never  be  stripped  off 
as  a  separate  layer,  but  is 
always  intimately  adherent 
to  the  subjacent  tissues. 

Beneath  the  albuginea  the  parenchyma  of  the  gland  is  further 
divided  into  an  outer  cortical  and  an  inner  medullary  substance. 

The  medullary  suhstance  has  a  spongy  texture,  and  is  of  a  reddish 
color.  It  contains  an  abundance  of  blood-vessels,  the  branches  of  which 

*  Waldeyer,  "  Eierstock  und  Nebeneierstock,"  Strieker's  "  Handbuch  der  Lehre  der 
Geweben,"  p.  545. 


Fig,  15. — Lonc^itudinal  section  of  ovary  from  a  person 
a.f?ed  eighteen  (eight  diameters).  1,  albuginea;  2, 
fibrous  layer  of  cortical  portion ;  3,  cellular  layer 
of  cortical  portion ;  4,  medullary  substance ;  6, 
loose  connective  tissue  between  the  firm  layers  of 
tlie  medullary  substance.  (Ilenle.) 


22 


PHYSIOLOGICAL  ANATOMY. 


pursue  a  spiral  course.  The  cortical  substance  is  of  a  grayish  color. 
In  it  a  multitude  of  small  follicles,  of  the  utmost  functional  impor- 
tance, lie  imbedded.    The  precise  description  of  these  follicles  will  be 

given  in  connection  with  the  sub- 
ject of  ovulation.  The  stroma  of 
the  cortical  substance  is  nowhere 
sharply  distinguished  from  that  of 
the  medullary  portion.  The  fibers 
of  the  stroma,  for  the  most  part, 
radiate  from  the  center  toward  the 
circumference.  Just  underneath 
the  albuginea,  however,  the  con- 
nective tissue  of  the  cortical  sub- 
stance presents  a  felted  arrange- 
ment. This  portion  is  termed  in 
the  illustration  (Fig.  15),  the  fibrous 
layer,  in  contradistinction  to  the 
more  central  portion,  which  is  large- 
ly composed,  in  the  neighborhood 
of  the  vessels  and  the  follicles,  of 
round  and  s]3indle-shaped  cells. 

The  Vessels  of  the  Uterus  and 
its  Appendages. — The  uterus  re- 
ceives its  arterial  supplies  from  the 
following  sources  :  1.  The  arteria 
uterina  liypogastrica.  This  artery, 
as  its  name  implies,  is  derived  from 
the  hypogastric.    It  first  pursues  a 


Fig,  16.— Arterial  vessels  in  a  uterus  ten 
days  after  delivery  ;  the  uterus  is  turned 
forward,  so  as  to  present  the  posterior 
aspect.  1,  fundus  uteri ;  2,  vaginal  por- 
tion ;  3,  3,  lig.  teres ;  4,  4,  Fallopian 
tubes ;  5,  right  ovary  ;  6,  abdominal  aor- 
ta ;  7,  art.  Inesenterica  inf. ;  8,^  8,  art. 

uterina  aortica  (spermatic  arteries)  ;  9,    ,  ,  ,  ,    , , 

9,  art.  iliaca  communis ;  10,  art.  iliaca  downward  COUrsC  tO  reach  the  Vagl- 

^^^^^^JSS:!'1^:ii^^  fornix,  where  its  pulsations 

may  be  felt  during  pregnancy. 
Thence  it  curves  upward  between  the  folds  of  the  broad  ligament,  and 
follows  a  tortuous  course  along  the  lateral  borders  of  the  cervix  and 
corpus  uteri.  It  distributes  small  branches  to  the  fornix  vaginse,  and 
large  ones  to  the  uterus.  The  uterine  branches  are,  in  part,  distrib- 
uted to  the  surface  of  the  uterus,  and,  in  part,  penetrate  the  muscular 
tissue,  to  form  a  thick  capillary  network  immediately  under  the  uter- 
ine mucous  membrane.  Of  surgical  interest  is  a  circumflex  branch, 
which  unites  the  arteries  of  each  side  with  one  another.  The  situation 
of  this  branch  is  just  at  the  junction  of  the  cervix  and  body.  During 
pregnancy  other  anastomotic  branches  are  developed.*    As  the  preg- 

*  IIyrtl  disputes  the  formation  of  anastomoses  during  pregnancy,  and  states  that  in 
the  pregnant  as  well  as  in  the  non-pregnant  uterus  none  but  capillary  communication  ex- 
ists between  the  arteries.  Hyrtl,  "  Topographische  Anatomic,"  Wien,  1865,  Bd.  ii,  p. 
194. 


FEMALE  ORGANS  OF  GENERATION.  23 

nant  uterus  is  situated  directly  under  the  abdominal  walls,  the  arterial 
murmurs  are  at  certain  points  distinctly  appreciable,  and  furnish  the 
auscultatory  sign  of  pregnancy  improperly  termed  the  placental 
bruit."  2.  The  orteria  uterina  aortica,  or  internal  spermatic  artery. 
The  origin  of  this  artery  is  situated  about  two  and  a  half  inches  above 
the  bifurcation  of  the  aorta.  It  pursues  a  serpentine  course,  and,  in 
places,  makes  spiral  turns,  which  are  specially  marked  during  preg- 
nancy. It  descends  obliquely  downward  under  the  peritonasum  to  the 
cavity  of  the  pelvis,  and  then  ascends  between  the  folds  of  the  broad 
ligaments  to  reach,  by  its  branches,  the  ovary,  the  Fallopian  tube,  and, 
by  its  main  trunk,  the  side  of  the  uterus,  where  it  forms  a  direct  com- 
munication with  the  art.  uterina  hypogastrica. 

This  communication  between  the  aortic  and  hypogastric  uterine 
arteries  serves  to  maintain  a  continuous  blood-current  during  gesta- 
tion. The  situation  of  the  uterine  artery  within  the  pelvic  cavity, 
and  its  exposure  to  pressure,  would  render  it,  were  it  the  sole  source 
of  blood-supply,  an  extremely  unsafe  dependence.  It  is  well  to  note 
here,  that  when  pressure  is  made  upon  the  aorta,  after  childbirth,  with 
a  view  to  checking  post-partum  haemorrhage,  the  manipulation  fails  to 
aifect  in  any  way  the  blood-stream  which  pours  into  the  uterus  from 
the  aortic  uterine  branches. 

The  beautiful  injections  of  Rouget  *  have  demonstrated  a  peculiar 
disposition  of  the  aortic  uterine  branches,  as  they  penetrate  the  body 
of  the  uterus.  Instead  of  dividing,  as  they  branch,  dichotomously, 
they  break  up,  on  reaching  the  vicinity  of  the  Fallopian  tubes,  into 
from  twelve  to  eighteen  arterial  tufts,  of  which  each  branch  is  twisted 
in  spiral  form.  These  tufts  of  vessels  are  so  aggregated  together  as 
frequently  to  cover  the  angles  of  the  uterus. 

The  veins  of  the  uterus  form  a  net-work,  which  traverses  the 
uterine  tissues  in  all  directions.  As  their  walls  are  intimately  adher- 
ent to  the  muscular  tissues  of  the  uterus,  they  remain  patulous  upon 
section,  and,  when  enlarged  by  pregnancy,  are  termed  "sinuses." 
Eouget  likewise  describes  twisted,  tangled  venous  ducts,  which  often 
form  spirals  like  those  described  in  the  arteries.  The  same  authority 
claims  that  the  ultimate  divisions  of  the  arteries  communicate  with 
the  venous  sinuses  by  very  fine  vessels,  measuring  from  5^-g^oth  to 
of  an  inch,  instead  of  by  capillary  networks. 

The  return-currents  of  the  uterus  empty  into  two  venous  jilexuses  : 

1.  The  plexus  uterinus.  This  plexus  receives  its  blood  from  the 
uterus  alone.  It  extends  between  the  folds  of  the  broad  ligament, 
and  empties  into  the  hypogastric  vein. 

2.  The  plexus  pampiniformis.  The  plexus  pampiniformis  derives 
its  blood  from  the  uterus,  the  Fallopian  tubes,  and  ovaries.    Its  vessels 

*  Rouget,  "Recherches  sur  les  Organes  Erectiles  de  la  Femme,"  "Jour,  de  la  Physi- 
ol.,"  1858,  t.  i,  pp.  320  et  seq. 


24 


PHYSIOLOGICAL  ANATOMY. 


combine  to  form  a  single  trunk,  the  vena  spermatica  interna,  which 
follows  the  course  of  the  artery  of  the  same  name,  and  empties,  on 
the  right  side,  into  the  vena  renalis,  on  the  left,  into  the  vena  cava. 


Fig.  ]7. — Uterine  and  utero-ovarian  veins  (plexus  pampiniformis).  1,  uterus  seen  from  the 
front ;  its  right  half  is  covered  by  the  peritonaeum ;  upon  the  left  half  may  be  seen  the 
plexus  of  utero-ovarian  veins  (internal  spermatic) ;  6,  utero-ovarian  vessels  covered  by 
peritongeum ;  7,  the  same  vessels  exposed ;  8,  8,  8,  veins  from  the  Fallopian  tube ;  9, 
venous  plexus  of  the  hilum  ovarii;  10,  uterine  vein;  11,  uterine  artery;  12,  venous 
plexus,  covering  the  borders  of  the  uterus ;  13,  anastomoses  of  the  uterine  with  the 
utero-ovarian  vein  (int.  spermatic).  (Sappey.) 

The  arteries  of  the  ovary  are  derived,  as  we  have  had  occasion  to 
notice,  from  the  internal  spermatic,  penetrate  the  medullary  substance, 
at  the  hilum  ovarii,  and  describe  a  spiral  course.  The  arterial  branch- 
es anastomose  within  the  ovary,  and  form  an  interlacement,  including 
spaces,  which  become  smaller  and  smaller  as  the  surface  of  the  gland 
is  approached.  The  veins  start  as  radicles  from  the  capillaries,  then 
rapidly  enlarge,  and  present  a  varicose  appearance.  By  their  anasto- 
moses they  form  a  plexus,  which  includes  spaces  of  very  irregular 
size.  The  blood  is  then  taken  up  by  venous  trunks,  which  run  parallel 
to  the  arterial  branches,  and  terminate  finally  in  the  internal  sper- 
matic vein  (termed  by  Sappey,  Fig.  14,  the  utero-ovarian  vein). 

Upon  the  basis  of  the  foregoing  description,*  Rouget  draws  a  par- 
allel between  the  structures  of  the  penis  and  those  of  the  corpus  uteri, 
and  claims  identity  between  the  two  organs.  One  feature,  however,  of 
the  erectile  tissue,  as  generally  understood,  is  wanting  in  the  uterus, 
viz.,  a  dense,  fibrous  sheath,  a  tunica  albuginea,  inclosing  the  erectile 
organ,  limiting  the  degree  of  its  distention  and  enhancing  its  tur- 
gidity. 

As  experimental  proof  that  the  uterus  possesses  erectile  properties, 
Rouget  has  shown  that,  when  an  injection  is  forced  by  the  spermatic 
artery,  in  the  dead  subject,  so  as  completely  to  distend  the  vessels  of 
the  body  of  the  uterus,  the  latter  becomes  elevated  in  the  pelvis,  and 
makes  a  movement  similar  to  that  performed  by  the  penis  during 
venereal  excitement. 

*  Rouget,  "  Rechcrehcs  sur  les  Organes  ^ rectilcs  de  la  Fcmme,"  "  Jour,  de  la  Physi- 
ol," t.  i,  pp.  338  et  seq. 


FEMALE  ORGANS  OF  GENERATION. 


25 


It  is,  however,  obvious  that  the  forcible  distention  of  the  vessels  of 
a  flaccid  uterus,  in  which  the  muscular  walls  are  deprived  of  their 
normal  tonus  by  death,  does  not  necessarily  represent  the  phenomena 
produced  during  life  by  the  turgescence  resulting  from  either  ovula- 
tion or  the  sexual  orgasm.  Unfortunately,  so  far  as  the  body  of  the 
uterus  is  concerned,  the  difficulties  in  the  way  of  direct  observation 
upon  the  living  subject  have  hitherto  rendered  the  settlement  of  this 
point  impossible. 

With  regard  to  the  cervix  uteri,  we  have  physiological  as  well  as 
anatomical  reasons  for  admitting  a  certain  kind  of  erectility.  To  be 
sure,  a  tunica  albuginea  is  wanting.  It  is,  therefore,  not  an  ideal  erec- 
tile organ.  But  it  is  among  the  occasional  unpleasant  experiences 
of  gynaecological  practice  that  a  simple  digital  examination,  made  for 
the  purpose  of  a  diagnosis,  may  evoke  the  venereal  orgasm.  Precise 
observations  as  to  the  phenomena  presented  by  the  accessible  portion 
of  the  uterus  during  the  orgasm  have  been  furnished  by  Wernich,* 
Litzmann,t  and  in  one  remarkable  case  by  Beck,  J  which  leave  very 
little  doubt  that  strong  erotic  excitement  is  attended  by  a  rigidity  of 
the  cervix,  which  produces  an  impression  upon  the  fingers  similar  to 
that  imparted  by  the  glans  of  the  male  organ  during  erection. 

The  following  anatomical  peculiarities  of  the  cervix  uteri  are  fur- 
nished by  Henle  :  The  walls  of  the  vessels  (arteries,  capillary  branches, 
and  veins)  are  characterized  by  an  extraordinary  development  of  the 
circular  layer  of  muscular  fibres.  For  instance,  in  vessels  measuring 
from  ^Vo  ToTT  of  an  inch,  the  diameter  of  the  bore  is  scarcely  one 
third  the  diameter  of  the  entire  vessel.  The  arrangement  of  the  ves- 
sels is  likewise  peculiar.  In  the  labia  uterina,  especially  within  the 
muscular  tissues,  small  branches  pass  directly  down  to  the  mucous  sur- 
face. These  branches  pursue  an  undulatory  course,  are  parallel,  and 
run  at  nearly  equal  distances  from  one  another.  Just  beneath  the 
mucous  surface  in  like  manner  the  veins  arise  and  make  their  way  up- 
ward parallel  to  the  arteries,  and  with  the  same  orderly  arrangement. 
The  capillary  connections  between  these  veins  and  arteries  are  situated 
just  beneath  the  epithelium,  where  they  form  looped  projections  into 
the  papillae.  In  the  plicae  palmatae  the  general  direction  of  the  vessels 
is  likewise  perpendicular  to  the  surface.  In  commenting  upon  these 
facts,  Henle  remarks  that  there  is  nothing  in  the  situation  of  the 
arterial  walls  that  would  call  for  their  special  development,  as  they  are 
not  particularly  exposed  to  external  pressure.  Where,  however,"  he 
says,  "  extraordinary  means  are  employed  in  maintaining  contraction, 
extraordinary  relaxation  and  dilatation  are  possible."    He,  therefore, 

*  Wernicii,  "  Die  Erectionsfahigkeit  des  unteren  Uterus-Abscbnittes,"  "  Bcitr.  zur 
Geburtsh.  und  Gynaek.,"  Bd.  i,  p.  296. 

f  Wagner's  "  Handworterbuch  der  Physiolocrie,"  Bd.  iii,  p.  53. 

X  Beck,  "  How  do  the  Spermatozoa  enter  the  Uterus  ?  "  "  Am.  Jour.  Obst.,"  Nov.,  1874. 


26 


PHYSIOLOGICAL  ANATOMY. 


premises,  as  at  least  probable^  "  that  the  changing  degrees  of  contrac- 
tility in  the  finer  vessels  may  serve  to  impart  a  sort  of  capacity  for 
erection,  or,  at  least,  turgescence,  to  the  cervical  and  vaginal  portion  " 
— an  anatomical  deduction  sustained,  as  we  have  seen,  by  physiologi- 
cal observation. 

A  similar  attempt  on  the  part  of  M.  Eouget  to  constitute  an  erec- 
tile organ  out  of  the  ovary  is  disposed  of  by  Sappey  as  follows  : 
''Erectile  tissue  is  formed  by  large,  short,  anastomosing  capillaries, 


Fig.  18. — Nerves  of  the  uterus.  ple.xus  uterinus  macrnus  ;  plexus  hypogastricus  ;  (7, 
cervical  tranirlion.  1,  sacrum  ;  2,  rectum ;  3,  bladder ;  4,  uterus ;  5,  ovary  ;'  6,  extremity 
of  Fallopian  tube.    (Frankenhaeuscr, ) 


supporting  muscular  trabeculoe,  and  into  which  open  the  ultimate 
divisions  of  the  arteries  ;  but  in  the  bulb  (the  vascular  portion  of  the 
ovary)  there  arc  neither  dilated  capillaries,  nor  areola?,  nor  trabeculae. 


FEMALE  ORGANS  OF  GENERATION. 


27 


The  analogy  signalized  by  M.  Eouget  is  therefore  much  more  appar- 
ent than  real. "  * 

The  Nerves. t — The  nerves  of  the  uterus  are  derived  from  the  gan- 
gliated  cords  of  the  sympathetic  system,  through  which  important 
connections  are  formed  with  all  the  abdominal  viscera.  Just  at  the 
bifurcation  of  the  aorta  there  is  a  broad  band  of  nerve  tissue  term.ed 
the  plexus  uterinus  magnus,  formed  by  the  coalescence  of  filaments 
from  the  spermatic  ganglia  (two  pairs  of  ganglia,  situated  upon  each 
side  of  the  inferior  mesenteric  artery)  and  filaments  derived  from  that 
portion  of  the  aortic  plexus  which  is  distributed  mainly  to  the  supe- 
rior mesenteric  artery  (plexus  mesentericus  superior,  Frankenhaeuser). 
About  an  inch  and  a  half  below  the  bifurcation  of  the  aorta  it  divides 
into  two  strands,  the  plexus  liypogastrici,  which  pass  right  and  left 
around  the  rectum  to  the  uterus  and  upper  portion  of  the  vagina. 
The  hypogastric  plexuses  receive  nerve  branches  from  the  lower  lum- 
bar and  three  upper  sacral  ganglia.  Upon  the  sides  of  the  rectum 
they  divide  each  into  two  portions,  of  which  the  smaller  passes  directly 
to  the  posterior  and  lateral  walls  of  the  uterus,  while  the  larger  con- 
tributes to  the  formation  of  the  cervical  ganglion. 

The  cervical  ganglion  is  a  large  plexus,  vdiich  mea'sures  during 
pregnancy  two  inches  in  length  by  one  and  a  half  inch  in  breadth. 
It  is  formed  by  the  concurrence  of  filaments  from  the  hypogastric 
plexus,  the  three  upper  sacral  ganglia,  and  the  first,  second,  and  third 
sacral  nerves.  The  cervical  ganglion  supplies  the  entire  uterus,  and 
especially  the  cervical  portion,  with  nerves.  Examined  with  the  naked 
eye,  these  nerves  are  soon  lost  sight  of  as  they  penetrate  the  walls  of 
the  uterus,  but  their  ultimate  filaments  have  been  traced  by  Franken- 
haeuser, in  microscopic  preparations,  to  tlie  muscular  element,  where 
they  apparently  terminate  in  the  nucleus  of  the  fibre-cell. 

The  Lymphatics. — AYe  have  already  had  occasion  to  notice  the 
probable  existence  of  lymph-spaces  in  the  uterine  mucous  membrane. 
In  the  muscular  tissue  of  the  uterus,  lymph-spaces  are  found  in  the 
delicate  connective  tissue  which  unites  the  muscular  bundles  together. 
Regular  lymphatic  vessels  are  found  in  the  connective  tissue  which 
accompanies  the  arterial  trunks  into  the  uterine  parenchyma.  A  net- 
work of  lymphatic  vessels,  with  dilated  and  constricted  portions,  and 
provided  with  valves,  exists  beneath  the  serous  coat.  The  lymph- 
spaces  of  the  uterine  mucous  membrane  communicate,  by  funnel- 
shaped  depressions,  with  the  lymph-spaces  and  lymphatics  of  the  mus- 
cular strata.  Just  beneath  the  external  muscular  layer,  upon  the 
lateral  borders  of  the  uterus,  are  large  receiving  vessels,  into  which 
empty  the  lymphatics  from  both  the  subserous  and  uterine  vessels. 

*  "  Traite  d' Anatomic,"  Paris,  1874,  t.  iv,  p.  691. 

\  For  latest  and  most  complete  account,  vide  Frankenhaeuser,  "  Die  Nerven  der 
Gebarmutter,"  Jena,  1867. 


28 


PHYSIOLOGICAL  ANATOMY. 


The  lymphatics  of  the  cervix  pass  to  the  glands  of  the  pelvic  cavity, 
while  those  of  the  border  and  fundus  follow  the  course  of  the  plexus 
pampiniformis  to  form  connections  with  the  lymphatics  of  the  lumbar 
region.* 

Development  of  the  Female  Generative  Organs. — Three 
connected  structures  make  their  appearance  on  either  side  of  the 
spinal  column,  at  an  early  period  of  fetal  existence,  which  need  to  be 

understood  by  those  who  would  gain  a 
clear  idea  of  the  developed  organs  of 
generation  in  the  female.  These  struct- 
ures are  the  Wolffian  bodies,  the  ducts 
of  Miiller,  and  the  rudimentary  organs 
which  are  destined  at  a  more  advanced 
period  to  become  the  ovaries. 

The  Wolffian  bodies  are  oblong  glan- 
dular structures,  temporary  in  character, 
which  are  thought  to  perform,  in  the 
embryo,  the  excretory  function  of  the 
kidney.  They  possess  ducts,  situated  at 
the  sides,  which  converge  together  below 
the  Wolffian  bodies  to  empty  into  the 
sinus  uro-genitalis. 

Two  organs,  destined  to  become  the 
ovaries,  make  their  appearance  upon  the 
inner  side  of  the  Wolffian  bodies.  They 
possess  at  first  an  elongated,  but  subse- 
quently assume  a  more  oval  appearance. 

The  ducts  of  Muller  are  secondary 
formations,  derived  from  the  Wolffian 
ducts.  They  begin  as  longitudinal  seams 
upon  the  latter,  and  finally,  by  deepening  of  the  furrows,  become 
separated,  and  form  solid  filaments,  which  pass  spirally  around  the 
Wolffian  ducts,  and  meet  in  the  median  line  to  descend  together  to 
the  sinus  uro-genitalis.  These  solid  filaments  next  become  hollow. 
By  the  eighth  week  the  lower  portions  of  the  filaments,  which  are 
in  apposition  with  one  another,  fuse  together,  and  furnish  the  first 
rudiments  of  the  uterus  and  vagina.  The  free  portions  of  the  fila- 
ments become  the  Fallopian  tubes.  Both  uterus  and  vagina  are  at 
first  divided  into  two  parts  by  a  common  partition-wall,  which  dis- 
appears subsequently  from  below  upward. 

The  uterus,  at  the  fourth  month  of  fetal  life,  presents  distinct 
traces  of  the  early  origin  from  the  ducts  of  Muller.    The  fundus  is 

*  Leopold,  "  Dio  Lymphgefiisse  der  normalen  nicht  schwangcren  Uterus,"  "  Arch,  f . 
Gynack.,"  Bd.  vi,  Ileft  I,  pp.  1  et  scq. ;  Luschka,  "  Die  Anatomie  des  menschlichen  Beck- 
ens,"  Tubingen,  1805,  p.  378. 


Fig.  19. — Rudimentary  sexual  organs. 
The  internal  organs  represented 
at  the  seventh  week  of  fetal  life  ; 
the  external  organs  belong  to  a 
later  period,  f,  spinal  column ; 
3,  3,  Wolffian  bodies;  5,  glands 
destined  to  become  the  ovaries  in 
the  female,  the  testicles  in  the 
male;  6,  Wolffian  duct;  7,  fila- 
ments of  Muller ;  8,  bladder ;  9, 
tubercle,  forming  the  rudiment  of 
either  the  clitoris  or  penis:  10, 
folds  destined  to  form  the  labia 
majora  (in  the  male  the  scrotum) ; 
11,  sinus  uro-genitalis;  12,  anus. 
(Luschka.) 


FEMALE  ORGANS  OF  GENERATION. 


29 


undeveloped.  The  ridges  of  the  arbor  vitae  uterina,  which  are  con- 
lined  at  a  later  period  to  the  cervix,  extend  the  entire  length  of  the 
uterus.  A  depression  at  the  fundus 
marks  the  point  of  union  between 
the  ducts  of  Miiller.  Two  cornua, 
or  horns,  are  thus  distinguishable 
upon  the  external  surface  of  the 
uterus.  About  the  eighth  or  ninth 
month  the  convex  fundus  is  devel- 
oped, and  the  cornua  disappear  ex- 
ternally, though  all  through  life  they 

are  traceable  upon  the  inner  surface  ^^i^.  20.— Uterus  and  its  appendages  in  the 
.     -,,       1  ,  /-T  foetus  at  the  end  of  the  fourth  month 

m  lateral  sections  of  the  uterus  (viae 


(natural  size),  external  view  :  a,  a, 
ovaries,  relatively  large,  nearly  as  long 
as  the  oviducts  ;  Z>,  the  Fallopiaii 
tubes  (oviducts) ;  c,  c,  round  ligaments ; 
uterus  ;  e,  vagina  ;  /,  vaginal  orifice, 
interior  view  :  a,  rami  of  the  arbor 
vitce,  extending  to  the  fundus  of  the 
uterus  ;  vaginal  portion  of  uterus  ;  c, 
vagina.  (Courty.) 


Fig.  13,  p.  19).  ^ 

Before  the  differentiation  of  sex 
has  taken  place,  the  external  organs 
of  generation  present  the  following 
appearances  :  Two  ridges,  or  folds, 
surround  a  central  opening  (sinus 

uro-genitalis),  which  either  unite  to  form  the  scrotum  of  the  male, 
or  develop  into  the  labia  majora  in  the  female.  Where  these  folds  join 
together  above,  there  is  a  small  jirojecting  body,  or  tubercle,  destined 
to  become  the  penis  or  the  clitoris.    In  either  case  the  lower  surface 


Fig.  21.— Uterus  unicornis  from  a  young  child,  posterior  aspect  (Pole),  a,  uterus  unicornis, 
left  half  of  uterus  undeveloped  ;  h  right  Fallopian  tube;  c,  left  Fallopian  tube,  excep- 
tionally present;      d^  ovaries,  e,  bladder.  (Courty.) 

of  the  tubercle  is  furnished  with  a  groove.  The  margins  of  the  groove 
extend  along  the  sides  of  the  sinus  uro-genitalis,  and,  in  the  develop- 
ment of  the  female  type,  become  the  labia  minora.  The  sinus  uro- 
genitalis  affords  a  common  aperture  for  the  bladder  and  internal  or- 
gans of  generation. 

AbisOrmalities  of  the  Uterus.— An  arrest  of  fetal  development 


30 


PHYSIOLOGICAL  ANATOMY. 


gives  rise  to  a  number  of  deviations  from  the  ordinary  uterine  type,  of 
which  we  borrow  from  Courty  the  following  as  of  direct  obstetrical 
imi3ortance. 

1.  Uterus  Unicornis.  —  The  one-horned  uterus  results  from  the 
atrophy  or  incomplete  development  of  one  of  the  filaments  of  Miiller, 


a 

Fio.  22. — Double  uterus  and  vatjina  from  a  girl  aged  nineteen  (Ersenmann).  a,  double 
vaginal  orifice  with  double  hiymen ;  J,  meatus  urethrse ;  c,  clitoris  ;  urethra ;  e,  the 
double  vagina;         uterine  orifices;  ^,  ^,  cervical  portions;  A,  A,  bodies  and  cornua; 

«,  ovaries ;      Ic^  Fallopian  tubes ;         round  ligaments ;       w,  broad  ligaments. 
(Courty.) 

while  the  other  continues  its  evolution.  We  then  have  a  uterus  which 
is  composed  of  a  single  lateral  half,  possessing  generally  but  one  Fallo- 
pian tube. 

2.  Uterus  Duplex,  or  Didelphys. — Both  filaments  of  Miiller  are 
developed,  but  do  not  become  united  together.  Thus  two  distinct 
uteri  are  produced,  of  which  each  represents  in  reality  the  half  of  a 
normal  uterus. 


FEMALE  ORGANS  OF  GENERATION. 


31 


Fig.  23. — Uterus  bicornis,  double  cavity  and  double  vagina,  from  a  girl  seventeen  years  of 
a^e.  c,  cervical  portions  united  together,  presenting  the  appeai-ance  ol'  a  single*^  cervix ; 
a,     the  two  cornua.  (Courty.) 


Fig.  24.— Uterus  cordiformis,  double  natural  size.  (Kussmaul.) 


32 


PHYSIOLOGICAL  ANATOMY. 


3.  Uterus  Bicornis. — Partial  union  of  the  filaments  of  Miiller  takes 
place,  but  without  reaching  the  ordinary  level  indicated  by  the  inser- 
tions of  the  round  ligaments.  The  upper  portion  of  the  uterus  is 
thus  divided  into  two  horns,  separated  by  a  furrow  from  one  another. 

4.  Uterus  Cordiformis. — The  uterus  remains  of  the  fetal  type  in- 
dicated in  Fig.  17.  Instead  of  a  complete  development  of  the  fundus, 
the  latter  remains  depressed,  and  presents  an  appearance  remotely 
resembling  the  heart  of  a  playing-card. 

5.  Uterus  Septus  Bilocularis. — Complete  union  of  the  two  fila- 
ments of  Miiller  has  taken  place,  but  the  common  wall,  formed  by 
their  coalescence,  persists.    We  thus  have  two  distinct  uterine  cavities. 


Fig.  25. — Uterus  septus  bilocularis.    Double  uterus,  with  simple  vagina,  seen  from  the  front. 
Left  walls  more  developed  in  consequence  of  pregnancy.  (^Cruveilhier.) 

The  septum  may  extend  the  whole  length  of  the  vagina,  and  give  rise 
to  a  double  vagina  ;  or  absorption  of  the  vaginal  septum  and  a  portion 
of  the  uterine  septum  may  have  taken  place,  so  that  we  may  have  a 
double  uterine  cavity  with  a  single  cervix,  uterus  semi-par titus. 


DEVELOPMENT  OF  THE  OVUM.  33 


PHYSIOLOGY  OF  THE  OYUM. 


CHAPTER  II. 

DEVELOPMENT  OF  THE  OVUM. 

The  Graafian  follicles  and  the  ovum. — Discharge  of  the  ova  from  the  ovary,  and  the 
formation  of  the  corpus  luteum. — The  migration  of  the  ovum. — Fecundation. — 
Changes  taking  place  in  the  ovum  subsequent  to  fecundation. — Nourishment  of  the 
embryo. — The  allantois  and  chorion. — The  deciduae. — The  placenta;  its  development 
and  structure. — Formation  of  the  umbilical  cord. — The  amniotic  fluid. 

The  physiology  of  the  ovum  comprises  its  genesis,  development, 
and  discharge  from  the  ovary,  its  fecundation,  and  the  entire  series 
of  subsequent  changes  by  which  the  simple  structure  of  the  germ 
becomes  converted  into  a  complex  organism  presenting  the  specific 
characteristics  of  the  parent. 


Fio.  26. — Section  of  Wolffian  body,  with  rudimentary  ovary  (embryo  of  chick,  fourth  day  of 
incubationV  I^iT,  Wolffian  body  ;  ?/,  section  of  Wolffian  duct ;  a,  a,  thickened  epithe- 
lium ;  0,  (luct  of  Muller ;  E^  earlv  stage  in  development  of  ovary  ;  (9,  primordial 
ova;  m,  mesentery  ;  Z,  lateral  wall  of  ovary.  (Waldeyer.) 

The  following  account  of  the  history  of  the  ovum  is  derived  from 
Waldeyer's  now  tolerably  familiar  work.* 

The  Graafiai^  Follicles  ai^d  the  Ovum. — In  the  embryo 

*  "  Eierstock  und  Nebencierstock,"  Stricker's  "  Handbuch  der  Lehre  von  den  Gewe- 
ben,"  Leipsic,  1871 ;  "Eierstock  und  Ei,"  Leipsic,  1870. 
3 


34 


PHYSIOLOGY  OF  THE  OVUM. 


of  the  chick,  by  the  fourth  day  of  incubation,  the  Wolffian  body 
is  covered  by  cylindrical  epithelium,  contrasting  sharply  with  the 
flattened  cells  of  the  peritonaeum.    Soon  after,  a  thickening  of  the 


Fig.  27. — Vertical  section  of  an  ovary  of  a  human  fatus  thirty -two  weeks  old.  a,  a,  epitlie- 
lium  ;  ^,  latest  developed  epithelial  cells,  situated  in  the  epithelial  layer;  c,  trabecule 
of  connective  tissue  which  have  penetrated  into  the  epithelial  layer  ;  e,  e,  primordial  fol- 
licles surrounded  by  fine  connective-tissue  cells  ; groups  of  imbedded  epithelial  cells, 
amona;  which  may  be  distinguished  certain  ones  of  large  size  (primordial  ova) ;  ^,  gi'anu- 
lar  cells  of  His.  (Waldeyer.) 

epithelium  becomes  noticeable  in  the  median  line,  and  forms  the 
earliest  trace  of  the  ovary.  Next,  a  small  rounded  elevation,  rich  in 
cells,  and  derived  from  the  interstitial  tissue  of  the  Wolffian  body, 
makes  its  appearance  underneath  the  thickened  epithelium.  The  epi- 
thelium is  destined  to  form  the  Graafian  follicles  and  ova ;  the  pro- 
liferated connective  tissue  furnishes  the  vascular  stroma  of  the  ovary; 
Between  the  fourth  and  fifth  day,  certain  cells  already  indicate  their 
destiny  as  future  ova,  by  their  size,  their  rounded  shape,  and  large  nu- 
clei. The  further  development  of  the  ovary  is  the  result  of  the  multi- 
plication of  the  epithelial  cells  and  the  continued  growth  of  the  stroma. 
As  the  connective-tissue  processes  grow  outward  and  penetrate  between 
the  cells,  the  latter  gradually  become  imbedded  in  the  stroma.  Thus, 
the  connective-tissue  processes  assume  a  trabecular  arrangement,  the 
meshes  of  which  are  filled  with  cell-masses  of  a  nearly  cylindrical  shape, 
which  hang  together  in  the  form  of  a  net- work.  Among  the  imbedded 
cells,  the  large  ones  already  noticed  are  termed  "  primordial  ova. "  The 
smaller  cells  remain  small,  and  arrange  themselves  like  epithelium 
around  the  larger  ones.  In  the  course  of  development,  the  interpene- 
tration  of  the  connective  tissue  continues,  until  each  primordial  ovum 
is  contained  in  its  own  separate  partition.  These  partitions,  with  the 
included  cells,  are  rudimentary  Graafian  follicles.  Two  distinct  ova, 
within  the  same  Graafian  follicle,  are  of  rare  occurrence.  As  the  ova 
enlarge,  and  the  epithelial  cells  multiply,  an  irritative  action  is  set  up 
in  tlie  surrounding  stroma.    An  increase  in  vascularity  results,  and  a 


DEVELOPMENT  OF  THE  OVUM.  35 

ring  of  young  connective  tissue  is  developed  about  each  epithelial  col- 
lection. As  the  ring  grows,  its  outer  layer  becomes  fibrillated.  Thus 
around  each  Graafian  follicle  a  distinct  envelope  is  formed,  termed  by 
Baer  the  theca  folliculi,  consisting  of  an  internal  vascular  coat,  the 
tunica  propria,  and  an  external  fibrillated  coat,  the  tunica  fibrosa. 

Each  primordial  ovum  is  at  first  encircled  by  a  single  layer  of 
cylindrical  cells.  Gradually  new  layers  form,  in  which  the  ovum  lies 
imbedded.  Afterward,  at  a  point  remote  from  the  ovum,  a  crescent- 
shaped  opening  makes  its  appearance,  which  becomes  filled  with  a 
clear  fluid  derived  from  transuded  serum,  and  possibly  in  part  from 


Fig.  28. — Portion  of  vertical  section  through  ovary  of  bitch,    cr,  epithelium  of  ovary  ;  6, 
tubules  of  ovary  ;  c,  voung  follicles  ;  d.  mature  follicles  •  e,  discus  proligerus,  with  ovum  ; 
epithcliuni  of  seconcf  ovum  in  same  follicle  ;  (7,  tunica  fibrosa  folliculi  •  /i,  tunica  propria 
foUicuIi ;     merabrana  granulosa.  (Waldeye'r.) 

disintegrated  epithelium.  A  heap  of  cells  remains  about  the  ovum, 
and  forms  the  discus  proligerus.    With  the  increase  of  the  follicular 


36 


PHYSIOLOGY  OF  THE  OVUM. 


fluid,  the  cylindrical  cells  are  pressed  against  the  membrana  propria, 
and  form  a  third  coating,  or  layer,  termed  the  membrana  granulosa. 

A  glance  at  a  transverse  section  through  the  ovary  of  a  mature 
mammal  exhibits  follicles  of  different  ages.    To  recapitulate  : 

The  young  follicles  are  composed  of  primordial  ova,  surrounded  by 
epithelium,  and  imbedded  in  the  ovarian  stroma. 

The  fully  developed  follicles  possess  a  vesicular  character.  They 
are  surrounded  by  a  connective-tissue  wall  (theca  folliculi),  which  is 
composed  of  two  layers  (tunica  propria  and  tunica  fibrosa).  The  tunica 
propria  is  lined  by  cells  (membrana  granulosa)  which  are  gathered  in 
heaps  (discus  proligerus)  around  the  ova.  The  discus  proligerus  is 
seated  sometimes  superficially,  sometimes  in  the  deepest  portion  of  the 
ovum.  Each  ovum  is  surrounded  by  a  special  layer  of  cylindrical  epi- 
thelium (epithelium  of  the  ovum). 

Henle  estimates  the  entire  number  of  Graafian  follicles  in  each  ovary 
at  thirty-six  thousand.* 


Fig.  29.— Ovum  from  a  Graafian  follicle  in  the  rabbit,    a,  epithelium  of  ovum ;  ft,  zona  radi- 
ata;  c,  germinative  vesicle  ;      germinative  spot ;  6,  vitellus.  (Waldeyer.) 

The  ovu7n,  at  the  time  of  its  discharge  from  the  ovary,  is  no  longer 
a  simple  cell,  composed  of  ordinary  protoplasm,  but  presents  the  fol- 
lowing characteristic  peculiarities  :  It  is  of  large  size.  In  the  human 
female  the  ovum  measures  about  of  an  inch.  It  possesses  a  thick, 
transparent  envelope,  termed  the  vitelline  membrane,  or,  from  the  man- 

*  Henle,  *'  Handbuch  der  Eingewcidelchre,"  Braunschweig,  1866,  p.  483. 


DEVELOPMENT  OF  THE  OVUM. 


37 


ner  in  which  it  transmits  light,  the  zona  pellucida.  The  zona  pellu- 
cida  was  formerly  thought  to  be  due  to  a  thickening  of  the  cell-mem- 
brane. It  is  now  more  commonly  regarded  as  something  superadded 
to  the  primordial  ovum.  Probably  the  attached  portions  of  the  radiate 
cells  which  surround  the  ovum  in  the  discus  proligerus  contribute  to 
its  formation.  The  appearances  in  Fig.  29  represent,  according  to 
Waldeyer,  these  cells  undergoing  a  cuticular  transformation.  The 
fine  lines  which  may  be  seen,  when  high  magnifying  powers  are  used, 
are,  he  believes,  unchanged  filaments  of  the  original  protoplasm.*  The 
thickness  of  the  zona  pellucida  is  from  to  ^  the  diameter  of  the 
ovum. 

The  body  of  the  cell  becomes  the  vitellus  or  yolh  of  the  ovum.  It 
possesses  contractility  and  other  properties  of  ordinary  protoplasm.  It 
has  a  viscid  consistence,  and  is  opaque  from  the  presence  of  very  fine 
granules  and  globular  vesicles. 

The  nucleus  of  the  cell  becomes  converted  into  a  large,  clear,  col- 
orless vesicle,  known  as  the  germinative  vesicle.  The  nucleolus  per- 
sists as  a  dark,  probably  solid,  body  within  the  germinative  vesicle, 
where  it  is  known  as  the  germinative  spot. 

Discharge  of  the  Ova  from  the  Ovary,  axd  the  Formation" 
OF  THE  Corpus  Luteum. — We  have  already  seen  that  the  number 
of  Graafian  follicles  within  a  single  ovary  is  estimated  at  thirty-six 
thousand.  The  formation  of  these  follicles  is,  in  great  degree  at 
least,  completed  during  the  antenatal  period  of  existence.  Previous 
to  puberty,  however,  they  remain  in  a  quiescent  condition.  With 
the  advent  of  puberty  the  ovaries  assume  functional  importance. 
The  surface  of  the  ovary,  if  examined  at  this  time,  is  no  longer 
smooth,  but  studded  with  small  vesicles.  These  vesicles  are  nothing 
more  than  the  enlarged  Graafian  follicles,  which,  as  they  become  dis- 
tended by  their  fluid  contents,  approach  the  periphery,  then  the 
tunica  albuginea,  and  form  rounded,  translucent  prominences.  By 
the  additional  disappearance  of  the  blood-vessels  and  the  lymphatics, 
a  weak  point  in  the  wall  of  the  follicle,  the  macula  or  stigma  folUculi, 
is  left  exposed. 

The  discharge  of  the  ovum  is  due  to  the  conjoint  action  of  a  fatty 
degeneration  of  the  cells  in  the  walls  of  the  mature  follicle  and  the 
formation  of  the  corpus  luteum. 

The  corpus  luteum  begins  by  an  abundant  cell-proliferation,  in 
which  both  the  follicular  epithelium  and  the  tunica  propria  partici- 
pate. Vascular  arches  push  forth  into  the  cavity  of  the  follicle,  and 
still  further  encroach  upon  the  already  crowded  space.  Finally,  a 
point  is  reached  at  which  the  follicle  ruptures,  and  its  contents,  in- 
cluding the  ovum,  are  discharged.    When  the  Graafian  follicle  has 

*  Waldeyer,  "  Eierstock  und  Nebeneierstock,"  Stricker's  "  Handbuch  der  Lehre  von 
den  Geweben,"  Lcipsic,  1871,  p.  554. 


38 


PHYSIOLOGY  OF  THE  OVUM, 


reached  maturity^  the  congestion,  occurring  at  the  time  of  the  menses, 
operates  unquestionably  in  a  most  effective  manner  to  the  accomplish- 
ment of  this  result. 

Immediately  follov/ing  the  rupture  of  the  Graafian  follicle,  blood 
is  effused  into  its  cavity.  The  active  proliferation  of  the  cells  of  the 
membrana  granulosa  continues.  At  the  same  time  a  process  of  disin- 
tegration ensues.  But,  in  place  of  a  degenerative  product,  the  disin- 
tegration furnishes  a  granular,  vitellus-like  substance  of  a  yellow  color. 
Examined  by  the  microscope,  in  addition  to  the  granular  mass,  glob- 
ules may  be  recognized,  which  are  not  precisely  fat,  but  correspond  to 
the  globules  contained  in  the  vitellus  of  the  ovum. 

While  the  above-mentioned  process  is  going  on,  an  abundant  trans- 
migration of  white  corpuscles  from  the  vascular  network  surrounding 
the  follicle  takes  place,  which  lift  up  the  granulosa  cells,  with  the 
pseudo-yolk  substance,  and  press  them  toward  the  center  of  the  fol- 
licle. Along  with  the  young  wandering  cells  (white  corpuscles),  vascu- 
lar offshoots,  like  small  papillae,  push  out  from  every  side  into  the 
epithelial  and  vitellus-like  masses.  As  the  larger  vessels  form  more 
marked  projections,  they  give  to  the  corpus  luteum  a  folded  ap- 
pearance. 

In  a  state  of  complete  development  the  corpus  luteum  consists  of 
— 1.  The  pseudo-yolk  substance,  mingled  with  effused  blood.  2.  The 
thickened  layer  of  the  granulosa  cells,  mingled  with  yolk-substance. 
It  is  this  layer  which,  to  a  great  extent,  forms  the  folded,  yellow  por- 
tion of  the  corpus  luteum.  3.  The  vessels  which,  with  the  wandering 
cells,  push  from  all  directions  into  the  epithelial  masses.  As  these 
vessels  reach  the  center  of  the  follicle,  a  complete  interpenetration  of 
the  connective  tissue  and  epithelial  elements  of  the  corpus  luteum 
results,  and  the  foldings  become  indistinct. 

Finally,  absorption  of  the  vitellus-like  substance  occurs ;  the  last 
vestiges  of  the  effused  blood  are  converted  into  blood-crystals  ;  the 
arterial  vessels  degenerate ;  the  epithelial  masses  and  the  connective- 
tissue  mesh-works  disappear  gradually,  until  at  the  last  only  a  white, 
stellate  cicatrix  remains. 

If  the  ovum  is  discharged  without  impregnation  taking  place,  the 
corpus  luteum  reaches  its  maximum  size  at  the  end  of  three  weeks, 
and  then  begins  to  decline,  until,  at  the  end  of  two  months,  it  is  re- 
duced to  an  insignificant  cicatrix.  But,  when  conception  occurs,  the 
changes  in  the  corpus  luteum  take  place  more  slowly.  The  corpus 
luteum  reaches  a  higher  state  of  development.  Its  increase  in  size 
continues  for  two  months.  It  then  remains  stationary  up  to  the  end 
of  the  sixth  month.  During  the  last  three  months  of  pregnancy  it 
gradually  loses  its  bright-yellow  color,  grows  smaller,  but  still  measures 
one  half  of  an  inch  in  diameter  at  the  end  of  the  period  of  gestation.* 

*  Dalton's  "  Treatise  on  Human  Physiology,"  Philadelphia,  1861,  pp.  564  et  scq. 


DEVELOPMENT  OF  THE  OVUM. 


39 


The  corpus  luteiim  of  pregnancy  is  often  termed  the  true  corpus 
luteum,  to  distinguish  it  from  the  more  trivial  variety  which  is  pro- 
duced by  the  rupture  of  a  Graafian  follicle  at  a  menstrual  period. 
The  latter  has  been  termed  the  false  corpus  luteum,  because  it  is  found 
in  virgins,  and  does  not  constitute  a  sign  of  preexistent  pregnancy. 

The  Migration  of  the  Ovum. — The  number  of  ova  in  each  ovary  has 
been  estimated  by  Henle  at  thirty-six  thousand.  Only  a  small  pro- 
portion of  them,  however,  meet  with  the  conditions  requisite  for  frui- 
tion. It  is  probable  that  many  ova  perish  while  still  surrounded  by  the 
stroma  of  the  ovary.  The  history  of  extra-uterine  pregnancies  teaches 
us  that,  in  some  instances  at  least,  the  ovum,  after  its  discharge 
from  the  Graafian  follicle,  escapes  into  the  abdominal  caviby.  It, 
therefore,  becomes  an  interesting  subject  of  inquiry  as  to  the  conditions 
which  ordinarily  determine  the  passage  of  the  ovum  from  the  ovary 
into  the  Fallopian  tube  of  the  corresponding  side.  It  will  not  do  to 
assume,  as  is  usual,  a  peculiar  erectility  of  the  Fallopian  tube,  which 
enables  it  to  apply  its  funnel-shaped  extremity  to  the  ovary,  just  at 
the  moment  of  the  rupture  of  the  Graafian  follicle.  Setting  aside  the 
inherent  improbability  of  the  existence  of  such  a  degree  of  intelligence 
in  the  fimbriae  as  would  lead  to  the  exact  adaptation  of  the  tube  to 
the  precise  point  at  which  the  ovum  is  to  be  discharged,  it  has  been 
proved  that  the  Fallopian  tube  possesses  none  of  the  characteristics  of 
erectile  tissue.  Injections  of  its  vessels  after  death  do  not  communi- 
cate to  it  the  slightest  change  of  form  or  place.* 

Muscular  action  has  also  been  often  invoked  to  explain  the  assumed 
manner  in  which  the  fimbriae  seize  the  ovary,  but  galvanization  of  the 
tubes,  practiced  upon  criminals  recently  executed,  produces  only  ver- 
micular contractions,  which  do  not  affect  the  position  of  the  fimbriae,  f 
Indeed,  when  we  remember  the  position  of  the  Fallopian  tubes  in  the 
pelvis,  and  bear  in  mind  that  they  are  at  all  times  necessarily  subjected 
to  the  pressure  of  the  intestines,  it  becomes  difficult  to  understand 
how  they  can  execute  any  very  extended  movements.  J 

In  the  absence  of  direct  experimental  proof,  the  suggestion  of 

*  RouGET,  "Les  Organes  Erectiles  de  la  Femme,"  "Jour,  de  la  Physiol,"  t.  i,  1858,  p. 
337. 

f  PIyrtl,  "  Handbuch  der  topographischen  Anatomie,"  Wien,  1865,  Bd.  ii,  p.  210, 
:j:  Henle,  "Handbuch  der  Eingeweidelehre,"  Braunschweig,  1866,  p.  4Y0.  Rouget 
{vide  "Organes  Erectiles,"  "Jour,  de  la  Physiol.,"  1858)  has  studied  with  great  care 
the  arrangement  of  the  muscular  fibers  situated  between  the  peritoneal  layers  of  the 
broad  ligament.  These  fibers  are  directly  continuous  with  the  delicate  external  muscular 
layer  of  the  uterus.  Certain  of  them  are  so  distributed,  according  to  Rouget,  as  to  pro- 
duce by  their  contraction  a  direct  approximation  of  the  fimbriae  to  the  ovary.  Henle  re- 
marks, by  way  of  criticism,  that  more  stress  might  be  laid  upon  these  fibers  were  they 
distributed  to  the  Fallopian  tubes  alone.  As,  however,  they  spread  likewise  over  the 
ovary,  their  probable  action  would  consist  in  drawing  both  ovary  and  tube  toward  the 
median  line. 


40 


PHYSIOLOGY  OF  THE  OVUM. 


Henle  that  the  passage  of  the  ovum  into  the  Fallopian  tube  is  due  to 
the  currents  produced  in  the  serum  by  the  ciliated  epithelium,  which 
covers  both  the  external  and  internal  surfaces  of  the  fimbriae,  is,  on 
the  score  of  probability,  entitled  to  the  most  consideration.  One  of 
the  fimbriae  (fimbria  ovarica.  Fig.  12,  p.  18)  is,  as  we  have  already 
seen,  permanently  attached  to  the  lower  angle  of  the  ovary.  It  is 
likely  that  the  ovum,  discharged  from  a  Graafian  follicle,  is  floated 
down  by  the  peritoneal  serum  toward  the  lower  and  outer  border  of ' 
the  ovary,  where  a  sufficient  current  is  present  to  insure  its  being 
caught  up  and  conveyed  into  the  infundibulum  tubae.  Failures  on 
the  part  of  the  ovum  to  reach  its  destination  are,  in  all  probability, 
not  uncommon.  Support  is  given  to  the  theory  of  the  importance  of 
the  ciliae  in  influencing  the  migration  of  the  ovum  by  the  observation 
of  Thiry,*  that  in  batrachians,  which  have  the  oviducts  fixed  to  the 
abdominal  walls,  and  situated  at  a  distance  from  the  ovary,  during 
the  rutting  period  little  pathways  of  ciliated  epithelium  form  in  the 
peritonaeum,  which  collectively  converge  toward  the  openings  of  the 
tubes,  f 

While  the  ovum  remains  in  the  ampulla,  or  dilated  portion  of  the 
tube,  its  further  progress  is  at  first  dependent  upon  the  movements  of 
the  ciliae ;  but,  after  the  isthmus  is  reached,  an  additional  propelling 
force  is  furnished  by  the  circular  muscular  fibres,  which  possess  a  peri- 
staltic action. 

Fecundation. — The  precise  point  at  which  fecundation  takes  place 
has  been  variously  ascribed  by  authors  to  the  tubes,  the  uterus,  and 
the  ovary.  The  occurrence  of  fecundation  within  the  uterus  may  be 
rejected,  as  it  has  been  sufficiently  demonstrated  that  the  passage  of 
the  ovum  to  the  uterus  requires  a  period  exceeding  ten  days  in  the 
human  female — a  period  far  exceeding  the  extra-ovarian  life  of  the 
ovum,  when  not  vivified  by  the  contact  of  the  male  element  of  genera- 
tion. Abdominal  pregnancies  prove  certainly  the  possibility  of  the 
ovary  becoming  the  seat  of  fecundation,  but  their  extreme  rarity  would 
lead  us  to  infer  that,  so  far  as  the  human  female  is  concerned,  in 
whom  it  is  fair  to  believe  the  ovum  not  uncommonly  fails  to  enter  the 
tube,  the  phenomenon  is  unusual.  A  priori  reasoning  leads  us,  how- 
ever, to  regard  with  Henle  the  ampulla,  with  its  arborescent  folds,  as 
specially  designed  for  a  receptacle  of  the  seminal  fiuid.  The  conges- 
tive condition  of  the  mucous  membrane,  its  canalicular  structure,  and 

*  Gottinger  "  Nachrichten,"  1862,  p.  171. 

f  Cases  of  the  complete  migration  of  the  ovum  from  the  ovary  of  one  side  to  the 
Fallopian  tube  of  the  opposite  side  are  not  readily  explained  by  any  hypothesis.  Yet  the 
occurrence  of  such  cases  is  undoubted.  Pregnancy,  for  instance,  may  exist  where  there 
is  complete  absence  or  closure  of  the  Fallopian  tube  upon  the  same  side  with  the  corpus 
luteum.  For  the  literature  of  the  subject,  vide  Schroeder's  "Lehrbuch  der  Geburts- 
hUlfe,"  4te  Auflage,  p.  22. 


DEVELOPMENT  OF  THE  OVUM. 


41 


the  contractions  of  the  muscuhir  fibres,  all  seem  intended  to  further 
the  intimate  contact  of  the  spermatozoa  with  the  ovum  after  it  has 
reached  this  situation.* 

The  semen,  contact  with  which  is  essential  to  the  fecundation  of 
the  ovum,  is  a  thick,  viscid,  albuminous  fluid,  of  a  whitish  color,  and 
a  peculiar  odor,  wliicli  has  been  compared  to  that  of  the  raspings  of 
bone.  When  examined  by  the  microscope,  it  is  found  to  contain  nu- 
merous minute  anatomical  elements,  termed  spermatozoa.  Each  sper- 
matozoon consists  of  an  oval  head  and  a 
long  filiform  extremity  or  tail.  The 
head  is  flattened,  and  measures  about 
-g^Vo^  of  an  inch  in  width.  When  seen 
in  profile,  it  presents  a  pyriform  appear- 
ance. The  entire  spermatozoon  meas- 
ures from  -g-J-Q  to  of  an  inch  in 
length. 

The  spermatozoa  do  not  simply  float 
in  the  seminal  fluid,  but  possess  the  ca- 
pacity of  moving  from  place  to  place, 

as  though  endOAVed  with  volition.      In-    Fig.  so— Spermatozoa  from  the  hu- 

deed,  as  the  observer  sees  them  advance,  SratlS^Sf  "(S^^^^ 
now  singly,  and  now  in  shoals,  now  div- 
ing down,  and  then  rising  again  to  the  surface,  now  avoiding  some 
obstacle,  or  skillfully  picking  their  way  between  masses  of  ej^ithelium, 
it  is  difficult  to  resist  the  conviction  that  they  are  really,  what  they 
were  long  supposed  to  be,  distinct  organisms  capable  of  a  certain  de- 
gree of  voluntary  action.  But  there  is  little  doubt,  at  the  present 
day,  that  the  undulatory  movements  of  the  tail,  which  furnish  the 
propelling  force,  are  due  to  purely  molecular  tissue-changes,  similar 
to  those  which  give  rise  to  the  amoeboid  movements  of  protoplasm  or 
the  oscillations  of  the  hair-like  processes  of  ciliated  epithelium. 

Henle  estimates  that  the  spermatozoa  travel  at  the  rate  of  an  inch 
in  seven  and  a  half  minutes.  It  is  to  these  bodies  that  the  semen  owes 
its  fecundating  power,  but  only  so  long  as  they  retain  the  faculty  of 
motion — a  faculty  which  has  been  found  to  exist  in  full  force,  v\^ithin 
the  female  genital  organs,  eight  to  ten  days  after  ejaculation,  f 

Our  knowledge  of  the  process  of  fecundation  is  limited  to  the  fact 
that  the  spermatozoa  penetrate  through  the  vitelline  membrane,  and 
then  dissolve  in  the  vitellus. 

In  1840  Martin  Barry  described  a  point  in  the  zona  pellucida  (vitel- 
line membrane)  of  the  rabbit,  which  appeared  to  him  to  be  an  opening 
designed  for  the  passage  of  spermatozoa.  At  first  embryologists  pro- 
nounced Barry's  descriptions  to  be  based  upon  an  illusion,  but  since 

*  Henle,  "  Ilandbuch  der  Eingeweidelehre,"  1866,  p.  476. 

f  LuscHKA,  "  Die  Anatomic  des  menschlichen  Beckens,"  Tiibingen,  1864,  p.  273. 


42 


PHYSIOLOGY  OF  THE  OVUM. 


then  the  existence  of  such  an  opening,  termed  later  bj  Keber  the 
micropyle,  has  been  abundantly  demonstrated,  at  least  in  the  ova  of 
fishes,  mollusks,  insects,  etc.* 

A  very  interesting  series  of  observations,  connected  with  this  sub- 
joct,  have  been  made  by  M.  Eobin  upon  the  ova  of  the  nephelis  vul- 
(jarisy  or  common  leech.  The  earliest  token  of  the  maturity  of  the 
ovum  consisted  in  the  disappearance  of  tlie  germinative  vesicle.  At  the 
same  time  a  retraction  took  place  in  the  viteilus,  which  became  thereby 
reduced  one  sixth  to  one  fourth  in  size.  At  first  the  removal  of  internal 
pressure,  consequent  upon  this  retraction,  led  to  a  wrinkling  of  the  vitel- 
line membrane.  Afterward,  however,  a  clear,  limpid  fluid,  probably  in 
part  exuded  from  the  viteilus  and  in  part  derived  by  endosmosis  from 
external  sources,  filled  up  the  intervening  space,  and  caused  the  wrin- 
kles to  disappear.    Th>e  spermatozoa,  in  their  movements  around  the 

ovum,  assumed  a  perpendicular  or 
oblique  direction  to  the  vitelline 
membrane.  At  one  point  in  the 
membrane  the  penetration  of  these 
bodies  could  be  distinctly  observed. 
At  the  end  of  an  hour  the  penetra- 
tion had  ceased,  and  then  a  littly 
bundle  of  spermatozoa  could  be  seen 
arrested,  partly  within  and  partly 
without  the  ovum.  In  the  clear, 
limpid  space  surrounding  the  vitei- 
lus, the  spermatozoa  continued  to 
move  about  actively  for  a  time,  but 
in  fifteen  to  twenty  minutes  their 
movements  began  to  grow  slow,  and 
in  a  couple  of  hours  had  ended  alto- 
gether. A  comparison,  by  actual  count,  of  the  spermatozoa  now  re- 
maining, showed  that  a  certain  number  of  those  which  had  found 
entrance  into  the  limpid  space  had  disappeared.  They  had  been 
absorbed  directly  into  the  viteilus,  to  serve  for  its  fecundation,  f 

Changes  takii^g  place  in  the  Ovum  subsequent  to  Fecun- 
dation. 

In  describing  its  anatomy,  we  have  noted  that  the  ovum  was  orig- 
inally a  simple  cell,  possessing  contractility  and  other  properties  of  liv- 
ing matter.  The  ova  of  certain  of  the  sponges,  which  do  not  possess  a 
zona  pellucida,  move  about  under  the  field  of  the  microscope  by 

*  Vide  Milne-Edwards,  "  Lc9ons  de  la  Physiologic,"  t.  viii,  Paris,  18*73,  pp.  361  ct 
seq. ;  Waldeyer,  "Eierstock  und  Nebeneierstock,"  St  ickkr's  "  Handbiicli,"  p.  354, 

f  "  M6moire  sur  les  Plienonienes  qui  se  passent  dans  I'Ovulc  avant  la  Segmentation  du 
Viteilus,"  KoBiN,  "  Jour,  de  la  Physiol.,"  t.  v,  pp.  67  el  seq. 


Fig.  31. — Ovum  of  the  nephelis  vulixaris, 
showing  retraction  of  viteilus  and  the 
penetration  of  the  spermatozoa  throua  h 
the  vitelline  membrane  (magnified 
three  hundred  diameters).  (Eobin.) 


DEVELOPMENT  OF  THE  OVUM. 


43 


pushing  out  finger-like  processes,  precisely  like  the  ordinary  amoeba.* 
Contractile  movements  of  the  vitellus  within  the  zona  pellucida  have 
been  described  by  Kobin  in  the  ova  of  the  leech  and  other  low  orders 
of  animal  life,  f 

Before  the  ovum  leaves  the  Graafian  vesicle,  or  soon  after  its  dis- 
charge from  the  ovary,  the  germinative  vesicle  disappears.  As  this 
disappearance  has  been  observed  mostly  in  the  impregnated  ovum,  the 
phenomenon  has  been  generally  attributed  to  the  penetration  of  the 
spermatozoa,  but  Robin  regards  it  as  simply  a  sign  that  the  ovum  has 
reached  maturity,  and  has  become  apt  for  fecundation.  It  occurs 
equally  within  the  unfecundated  ovum.  J 

The  first  decided  indication  of  the  changes  effected  in  the  ovum  by 
contact  with  the  male  element  of  generation,  and  a  sign,  too,  conclusive 
of  fecundation,  is  the  spontaneous  appearance  of  a  round  nucleus  in 
the  center  of  the  vitellus.  This  nucleus  is  recognizable  fifteen  to  thirty 
hours  after  fecundation.  In  appearance  it  so  closely  resembles  the 
original  germinative  vesicle  that,  for  a  long  time,  it  was  erroneously 
regarded  as  such. 

Almost  immediately  after  its  production,  the  vitelline  nucleus  sub- 
divides into  two  nuclei.  By  a  similar  process  of  cleavage,  the  vitellus 
likewise  separates  into  two  halves.    The  nuclei  act  as  central  points 


Fig.  32._— Sedimentation  of  the  ovum.  A,  the  ovum  divided  into  two  cells ;  the  two  cells 
divided  into  four ;  f,  the  four  cells  divided  into  eiefht ;  D,  by  repeated  segmentation  the 
ovum  has  become  a  round,  mulbeiTj-shaped  mass— the  morula.    (Hacckel. ) 


of  attraction,  around  which  collect  the  molecular  and  viscid  portions 
of  the  protoplasm.  In  this  manner  the  original  cell  is  converted  into 
two  new  cells,  exactly  resembling  one  another,  and  both  lying  near 
together  within  the  vitelline  membrane.  To  this  cleavage  of  cells  the 
term  segmentation  has  been  applied.  By  a  continuation  of  the  process, 
the  two  new  cells  are  converted  into  four,  the  four  into  eight,  and  so  on 
in  succession  until,  finally,  a  great  multitude  are  generated,  all  closely 
crowded  together,  and  giving  to  the  ovum  a  mulberry  appearance, 

*  Haeckel,  "  Anthropogcnie,"  Lcipsic,  18'74,  p.  112. 
f  Loc.  cit.,  pp.  100  d  seq. 

X  Robin,  "  Sur  la  Production  du  Noyau  Vitellin,"  "  Jour,  de  la  Physiol.,"  t.  v,  p.  315. 


44 


PHYSIOLOGY  OF  THE  OVUM. 


whence  the  term  morula  has  been  applied  to  the  ovum  at  this  stage  of 
its  development. 

A  clear  fluid  next  accumulates  in  the  center  of  the  morula,  at  first 
small  in  amount,  but  gradually  increasing  in  quantity  until  finally 
the  cells  are  pressed  to  the  surface.  Thus  the  morula  is  converted 
into  a  globular  vesicle,  termed  the  hlastodermic  vesicle  (Fig.  33). 
The  walls  of  the  latter  are  composed  of  a  single  layer  of  cells,  which 
form  a  continuous  membrane,  termed  the  hlastodermic  membrane.  By 
the  absorption  of  fluid  in  its  transit  through  the  Fallopian  tube,  the 
ovum  is  increased,  upon  the  completion  of  the  blastodermic  membrane, 
from  y|  0^  of  an  inch  to  from  -^-^  to      of  an  inch  in  diameter. 

All  the  cells  resulting  from  the  segmentation  of  the  original  vitel- 
lus  do  not,  however,  take  part  in  the  formation  of  the  blastodermic 
membrane.  If  we  carefully  examine  the  blastodermic  vesicle,  just 
after  its  development,  we  find,  at  one  point  upon  its  surface,  a  dark, 
round  spot,  which  is  caused  by  an  accumulation  of  a  portion  of  the 
cleavage  cells  upon  the  inner  surface  of  the  membrane.    In  profile  this 

spot  presents  a  semicircular  projection 
within  the  vesicle.*  By  peripheral  ex- 
tension, its  cells  gradually  spread  over 
and  line  the  inner  surface  of  the  blasto- 
dermic membrane.  Thus  the  ovum  be- 
comes encompassed  by  two  cell-mem- 
branes, termed  respectively  the  outer  and 
the  inner  layer  of  the  blastodermic  mem- 
brane. The  outer  layer  of  the  blasto- 
dermic membrane  is  likewise  termed  the 
ectoderm,  in  distinction  from  the  inner 
layer,  or  entoderm. 

At  the  same  time  a  stratum  of  fluid 
forms  between  the  external  layer  of  the 
blastodermic  membrane  and  the  cliorioyi, 
as  the  zona  pellucida  is  noAV  called.  Be- 
fore the  completion  of  the  entoderm,  a 
bright,  round  spot  makes  its  appearance 
upon  the  surface  of  the  blastodermic  ves- 
icle. This  spot  marks  the  point  at  which 
all  the  more  important  processes  connected  with  the  development  of 
the  embryo  take  place,  and  is  termed  the  area  germinativa.  At  the 
outset,  it  differs  from  other  portions  of  the  blastodermic  vesicle  solely 
in  the  increased  thickness  of  the  cells  composing  the  ectoderm.  Those 
of  the  entoderm  remain  unchanged. 

*  The  theory  of  BischofF  and  others,  that  the  area  germinativa  is  developed  at  this 
point,  is  not  supported  by  the  recent  investij^ations  of  Kolliker.  —  Albert  Kolliker, 
"  Entwickelungs-Geschichte,"  erste  Halftc,  p.  227,  Leipsic,  1876. 


Fig.  S3. — Blastodermic  vesicle  from 
the  uterus  of  the  rabbit,  a, 
chorion  ;  cells,  resulting  from 
segmentation,  forming  a  "single 
layer  lining  the  chorion — these 
cells  have  become  hexagonal 
from  reciprocal  pressure  ;  c, 
heap  of  cells  remaining  within 
the  blastodermic  vesicle  after 
the  formation  of  the  blastoder- 
mic membrane.  (Bischoff.) 


DEVEI-OPMENT  OF  THE  OVUM. 


45 


The  area  germinativa  has  later  an  oval  shape,  with  a  bright  center 
and  a  dark  border.  The  clear  center  is  termed  the  area  pellucida,  and 
the  dark,  thickened  border  the  area  opaca  (Fig.  35). 


Fig.  34.— Section  through  area  germinativa  in  the  egg  of  a  rabbit,  showing  the  thickening  of 
the  ectoderm  iect.)"a.t  that  "point,  as  contrasted  with  the  ectoderm  ot'  the  blastodermic 
vesicle  beyond  the  area  germinativa  {vg.).  (Kollikcr.) 


Subsequently  a  third,  intermediate,  cell-layer,  termed  the  mesoderm, 
is  developed  between  the  ectoderm  and  the  entoderm.*  In  the  meso- 
derm are  developed  the  primitive  blood-vessels,  with  the  growth  of 
which  the  area  germinativa  becomes  known  as  the  area  vasculosa. 

Finally,  the  mesoderm  separates 
into  two  distinct  strata,  so  that  the 
embryo,  at  one  stage,  is  composed  of 
four  distinct  layers. 

Without  entering  minutely  into 
the  subject,  it  may  be  well  to  state 
that,  according  to  common  accept- 
ance, these  layers  are  assumed  to 
have  the  following  relations  to  the 
ulterior  development  of  the  body  : 

The  outer  layer,  or  ectoderm,  is 
concerned  in  the  formation  of  the 
epidermis,  hair,  nails,  the  glandular 
structures  of  the  skin,  the  brain,  the 
spinal  cord,  the  organs  of  special 
sense,  and  perhaps  in  that  of  the 
geni  to-urinary  system. 

The  second,  or  outer,  stratum  of 
the  mesoderm  gives  rise  to  the  cori- 
um,  the  muscles  of  the  trunk  (those 
concerned  in  the  movement  of  the 
body),  and  the  bony  framework. 

The  third,  or  inner,  stratum  of 
the  mesoderm  supplies  the  muscular 
and  fibrous  tissues  of  the  digestive  tract,  the  blood,  the  blood-vessels, 
and  the  blood -glands. 

*  Accordinp:  to  Kollikcr,  the  cells  of  the  mesoderm  are  derived  solely  from  the  pro- 
liferation of  those  of  the  ectoderm  :  "  Entwickelungs-Geschichte,"  2te  Auflage,  p.  268. 


Fig,  35. — Area  germinativa,  from  the  ovum 
of  a  rabbit,  enlarged  about  ten  diame- 
ters.   On  account  of  the  dark  back- 

fTound  the  semi-transparent  area  pel- 
ucida  looks  dark,  whereas  the  area 
opaca  and  the  embryonic  spot  both 
appear  white.  Tlie  dark  line  in  tlie 
center  is  the  primitive  trace.  (Haeck- 
cl.) 


46 


PHYSIOLOGY  OF  THE  OVUM. 


The  inner  layer,  or  entoderm,  furnishes  the  epithelium  lining  the 
walls  and  glands  of  the  intestines.* 

About  the  time  the  area  germinativa  loses  its  circular  form,  and 
there  appears  in  the  middle  of  the  area 
pellucida  a  large,  dark,  oval  spot,  produced 
by  the  multiplication  at  that  point  of  the 
cells  belonging  to  the  outer  and  interme- 
diate layer,  and  termed  the  embryonic  spot, 
or  by  some  authors  the  protosoma,  because 
it  represents  the  most  primitive  stage  in 
the  development  of  the  embryo.  The  oval 
shape  of  the  embryonic  spot  is  suggestive 
of  the  future  distinction  between  the  head 
and  the  posterior  extremity,  the  larger 
end  corresponding  to  the  former,  and  the 
smaller  to  the  latter.  Then,  of  a  sudden, 
there  appears  in  the  middle  of  the  embry- 
onic spot  a  delicate  line  termed  the  prim- 
itive trace,  which  divides  it  into  two  later- 
al halves.  The  primitive  trace  consists  of 
a  groove  or  furrow,  bordered  by  two  ridges, 
termed  the  dorsal  plates,  and  formed  by 
a  thickening  of  the  external  layer.  The  dorsal  plates  may  be  readily 
understood  by  reference  to  the  transverse  section  (Fig.  36),  taken 
from  Professor  Dalton's  '^Treatise  on  Human  Physiology." 

Upon  microscopic  examination  of  such  a  transverse  section,  the 
embryo  is  found  to  be  composed  of  three  layers,  which,  in  the  verte- 
brata,  are  united  together  in  the  median  line.    The  intermediate  layer 


Fig.  37. — Transverse  section  tlirough  the  embryo  of  the  cliick  a  few  hours  after  the  com- 
mencement of  incubation.  A,  external  layer  of  the  blastodermic  membrane  ;  m,  external 
stratum  of  intermediate  layer ;  J\  internal  stratum  of  intermediate  layer ;  <i,  internal 
layer  of  the  blastodermic  membrane;      primitive  trace  or  furrow;  x,  chorda  dorsalis. 

(mesoderm),  which  possesses  the  greatest  thickness,  already  presents 
the  appearance  of  two  closely  connected  strata.  The  primitive  trace 
may  be  recognized  in  the  middle  of  the  upper  surface,  and  the  dorsal 
plates  are  seen  rising  up  as  low  ridges.  At  the  same  time,  just  be- 
neath the  furrow,  a  C3dindrical  organ,  known  as  the  cliorda  dorsalis, 
becomes  separated  from  the  cell-mass.    The  chorda  dorsalis  owes  its 

*  IIaeckel,  "  Anthropogenic,"  p.  218. 


becomes  of  an  oval  shape. 


Fig.  36. — Transverse  section  of 
egg  in  early  stage  of  develop- 
ment. Ij  external  and  median 
layers  of  blastodermic  mem- 
brane ;  2,  2,  dorsal  plates ;  3, 
internal  layer  of  blastodermic 
membrane.  (Dalton.) 


DEVELOPMENT  OF  THE  OVUM. 


47 


importance  to  the  fact  that  it  is  around  this  cylindrical  body  that  the 
vertebrae  subsequently  form.  The  vertebrae  themselves  are  derived 
from  two  longitudinal  chords, 
separated  by  a  cleavage  from  the 
portions  of  the  intermediate  layer 
next  to  either  side  of  the  chorda 
dorsalis.  The  peripheral  portions 
of  the  intermediate  layer  are  now 
termed  the  lateral  or  abdominal 
plates.  Meantime  the  dorsal 
plates  continue  to  grow,  and,  by 
curving  toward  one  another,  final- 
ly meet  in  the  median  line,  so  as  to  form  a  closed  tube,  the  tubus 
medullaris,  in  which  is  developed  the  central  nervous  system.  Thus 
it  will  be  noticed  that  the  organ  through  the  agency  of  which  the 
individual  is  brought  into  contact  with  the  external  world  is  primi- 
tively derived  from  the  external  blastodermic  layer  (ectoderm). 


Fig.  53. — Transverse  section  through  the  em- 
bryo of  a  chick  at  tlie  end  of  tlie  first  day 
of" incubation  (magnified  twenty  diame- 
ters), w,  dorsal  plates  ;  c  A,  chorda  dor- 
salis ;  V,  vertebral  chords  ;  a abdominal 
plates. 


Fig.  39. — Transverse  section  through  the  embryo  of  a  chick  on  the  second  day  of  incubation 
(magnified  one  hundred  diameters),  t  m,  the  dorsal  plates  have  closed  to  form  tubi/s 
medullaris /  the  connection  with  the  outer  or  cutaneous  layer  (c)  is  broken  off;  c7i, 
chorda ;  ■y,  vertebral  chords  ;  a  the  abdominal  plates,  have  separated  into  an  external 
and  internal  stratum,  united  at  m  to  form  the  mesenteric  folds. 


The  intermediate  layer  (mesoderm)  now  separates  into  an  internal 
and  external  stratum,  the  existence  of  which,  it  has  been  noted,  was 
indicated  at  an  earlier  stage.  These  two  strata  remain  united  by  their 
inner  borders,  and  form  later  at  the  point  of  union  the  mesenteric 
folds.  The  outer  extremities  of  the  inner  of  these  strata  now  curve 
inward,  and  finally  unite  together  to  form  the  intestine.  They  in- 
close at  the  same  time  the  internal  layer  of  the  blastodermic  mem- 
brane (entoderm).  The  closure,  unlike  that  of  the  dorsal  plates, 
takes  place  from  front  to  rear,  as  well  as  from  the  two  sides.  The  in- 
testinal tube  is  thus  formed  from  the  inner  stratum  of  the  mesoderm, 
which  furnishes  the  fibro-muscular  tissues,  and  from  the  internal 
blastodermic  layer  (entoderm),  from  which  the  glandular  structures 
are  derived.  A  portion  of  the  blastodermic  vesicle  is,  however,  not 
included  in  the  intestinal  tube,  but  hangs,  during  the  early  nionths  of 
gestation,  from  the  body  of  the  embryo,  and  is  termed  the  umbilical 
vesicle  {u  v).    Finally  the  outer  or  cutaneous  layer  of  the  blastoder- 


48 


PHYSIOLOGY  OF  THE  OVUM. 


niic  membrane  (ectoderm)  and  the  outer  stratum  of  the  mesoderm 
(the  fibro-muscular  layer  of  the  trunk)  curve  forward  and  inward  so 

as  to  inclose  a  long  cavity,  the 
coelum,  which  surrounds  the  in- 
testine. This  cavity  in  mam- 
mals subsequently  becomes  divid- 
ed by  the  diaphragm  into  thorax 
and  abdomen. 

The  body  of  the  embryo,  seen 
in  profile,  at  the  time  these 
changes  are  going  on,  possesses 
a  thickened  anterior,  or  cephalic 
portion,  and  a  tapering  posterior 
extremity.  It  manifests  at  an 
early  period  a  tendency  to  elevate 
itself  above  the  level  of  the  area 
germinativa.  The  back  becomes 
arched,  and  the  extremities  ap- 
proximate toward  one  another. 
Fluid  collects  between  the  two 
strata  of  the  mesoderm,  and  sep- 
arates them  from  one  another. 
Of  these  the  outer  stratum  forms 
a  union  with  the  cutaneous  layer 
so  as  to  produce  a  single  mem- 
brane, folds  of  which  rise  at  the 
same  time  from  the  extremities 
and  sides  of  the  embryo,  and  en- 
compass it  with  an  outer  wall  or 
parapet.  In  the  process  of  growth  these  folds  approach  one  another 
over  the  dorsum  of  the  embryo,  and  finally  unite  together.  Thus 
a  sac,  including  the  embryo,  is  formed,  termed  the  amnio7i,  the  cavity 
of  which  subsequently  fills  with  fluid. 

Nourishment  of  the  Embryo. 

It  now  becomes  a  matter  of  importance  for  us  to  consider  the 
sources  from  which  the  embryo  receives  the  nutritive  materials  requi- 
site for  its  further  growth  and  development. 

We  have  seen  already  that  the  ovum,  in  its  passage  through  the 
Fallopian  tube,  is  increased  in  size  by  absorption  of  albuminous  ma- 
terial from       of  an  inch  to  from  -^V  inch. 

In  describing  the  formation  of  the  intestinal  tube,  it  was  noted 
that  a  portion  only  of  the  blastodermic  vesicle  was  included  by  the 
curving  inward  of  the  inner  stratum  of  the  mesoderm,  while  a  portion, 
known  as  the  umbilical  vesicle,  hung  from  tlie  abdomen.    The  um- 


FiG,  40. — Section  through  the  ovum  of  chick 
after  development  of  umbilical  vesicle. 
c  A,  chorda  dorsalis  ;  t  m,  tuba  medullaris  ; 
0  outer  layer  of  mesoderm,  from  which 
are  formed  the  bony  skeleton,  the  blood- 
vessels, and  large  muscles  of  the  trunk; 
ect^  ectoderm  ;  int^  intestinal  tube, 
formed  from  the  inner  stratum  of  the 
mesoderm  and  the  entoderm  {ent) ;  u  v, 
umbilical  vesicle,  continuous  with  intes- 
tine ;  a  jo,  abdominal  plates,  formed  from 
the  outer  stratum  of  the  mesoderm  and  the 
ectoderm.  Eventually  the  abdominal  plates 
meet  to  inclose  the  cavity  of  the  trunk 
(thorax  and  abdomen)  ;  a  m,  amnion, 
formed  from  ectoderm  and  outer  stratum 
of  the  mesoderm  ;  zona  pellucida ;  L 
outer  lamina  of  the  amniotic  folds,  derived 
from  the  ectoderm. 


DEVELOPMENT  OF  THE  OVUM. 


49 


a 

a 

Fig.  41. — Diagram  showing  early 
stage  in  development  of  amnion, 
cf,  a,  external  layer  of  blastoder- 
mic membrane,'  rising  up  over 
the  dorsum  of  embryo  to  form 
the  amniotic  folds  ;  p,  allantois  ; 
V,  umbilical  vesicle. 


bilical  vesicle  is  lined,  like  the  intestinal  tube,  by  the  inner  layer  of 
the  blastodermic  membrane  (entoderm),  and  is  covered  by  an  exten- 
sion of  the  inner  stratum  of  the  meso- 
derm. At  first  the  cavity  of  the  vesicle 
communicates  with  the  intestine,  and 
contributes  by  its  contents  to  the  nour- 
ishment of  the  embryo.  This  arrange- 
ment, however,  is  only  temporary.  The 
passage  very  soon  becomes  obliterated, 
and  the  remains  of  the  umbilical  vesicle 
hang  downward,  attached  by  an  imper- 
vious pedicle  to  the  intestine. 

From  the  time  the  ovum  has  passed 
into  the  uterus,  however,  it  derives  it 
main  nutritive  supply  from  the  mucous 
membrane  of  that  organ,  at  first  by  sim- 
ple absorption,  and  afterward  by  the  for- 
mation of  the  placenta,  an  organ  through 
which  the  blood  of  the  fa?tus  circulates, 

separated  from  that  of  the  mother  by  the  thinnest  of  partitions. 
Through  the  party -wall  there  pass  to  the  foetus  all  the  materials 
necessary  for  existence  and  growth,  and  from  the  foetus  the  excrementi- 
tious  principles  representing  the  waste  which  is  incident  to  vital  action. 

There  is  nothing  in  physiology  more  interesting  than  the  process 
by  which  the  circulation  of  the  foetus  is  brought  into  close  relation 

with  that  of  the  mother.  It  in- 
cludes tlie  consideration  of  the 
allantois,  the  chorion,  the  decidua, 
and  finally  the  joint  product  of 
them  all,  viz.,  the  pJacerda. 

The  Allantois  and  Chorion. — 
The  cliorion  is  the  external  mem- 
brane that  invests  the  ovum.  Be- 
fore the  formation  of  the  amnion 
it  consists  simply  of  the  zona  pel- 
lucida  or  vitelline  membrane.  As 
the  ovum  is  received  into  the  ute- 
rus, the  vitelline  membrane  be- 
comes covered  with  amorphous  vil- 
li, which  help  to  fix  the  ovum  in 
the  uterine  cavity. 

After  the  completion  of  the  am- 
nion by  the  closure  of  the  amniotic 
folds,  it  remains  for  a  time  attached  to  the  outer  lamina  of  the  ecto- 
derm, at  the  point  where  the  folds  meet  over  the  back  of  the  embryo. 


Fio.  42. — Diagram  showin,:^  completion  of 
the  amnion  and  formation  of  the  chori- 
on, a,  amnion  •  2,  outer  lamina  of  the 
ectoderm  after  closure  of  amniotic  folds  ; 
jO,  allantois  ;      umbilical  vesicle. 


50 


PHYSIOLOGY  OF  THE  OVUM. 


Fig.  43. — Human  embryo,  at  the  third  week,  show- 
ing villi  covering  the  entire  chorion.  (Haeckel.) 


The  outer  lamina  meantime  expands  until  it  comes  in  contact  with 
the  vitelline  membrane,  which  then  disappears.     Thus  the  outer 

lamina  becomes  in  turn  the 
external  covering  or  chorion. 
The  new  chorion,  like  the 
one  it  superseded,  is  speedily 
covered  by  a  growth  of  non- 
vascular villosities.  These 
villosities  are  not  solid,  but 
hollow,  like  the  finger  of  a 
glove.  They  soon  reach  an 
extraordinary  development. 
New  villi  sprout  upward 
from  the  chorion,  the  older 
ones  push  out  buds  and 
lateral  offshoots,  so  that  al- 
ready in  the  third  week  the 
entire  surface  of  the  ovum 
is  covered  with  a  dense  for- 
est of  villi,  presenting  the 
most  delicate  and  graceful 
characters. 

We  have  just  noted  that  the  umbilical  vesicle  was  a  temporary 
structure,  and  only  for  a  brief  period  of  physiological  importance. 
Meantime  a  new  organ  is  developed,  by  means  of  which  a  vascular 
connection  is  established  between  the  embryo  and  the  villi  of  the 
chorion.  This  organ  is  termed  the 
allantois.  The  allantois  begins  as  a 
sac-like  projection  from  the  posterior 
extremity  of  the  intestine,  at  the  time 
when  the  amniotic  folds  rise  up  in 
the  form  of  an  embankment  around 
the  embryo  {vide  Fig.  41).  At  tliis 
time  the  umbilical  vesicle  is  still  very 
large.  The  allantois,  like  the  um- 
bilical vesicle  and  the  intestine,  is 
composed  of  two  layers  derived  re- 
spectively from  the  internal  layer  of 
the  blastodermic  membrane  (ento- 
derm), and  the  inner  stratum  of  the 
mesoderm.  It  speedily  becomes  vas- 
cular, and  increases  rapidly  in  size. 
The  inner  surfaces  of  the  sac  soon 
adhere  together,  so  as  to  form  a  single  membraije.  In  the  course  of 
the  third  week  the  allantois  reaches  the  chorion,  over  which  it  spreads 


44. — 1,  exochovion  ;  2,  blastodermic 
chorion-  w,  uiiibilical  vesicle-,  a,  am- 
nion ;  /y,  pedicle  of  allantois. 


Fig.  45. 


1.  Human  embryo,  at  the  ninth  week,  removed  from  the  membranes ;  three  times  the  natural 

size.  (Erdl.) 

2.  H;iman  embryo,  at  the  twelfth  week,  inclosed  in  the  amnion ;  natural  size.  (Erdl.) 


DEVELOPMENT  OF  THE  OVUM. 


51 


and  forms  a  complete  vascular  lining.  According  to  the  usual  accep- 
tation, the  vessels  of  the  allantois  everywhere  penetrate  into  the  villi 
of  the  chorion.  Then  the  chorion  and  allantois  fuse  together  and  form 
hy  their  consolidation  a  compound  membrane  termed  the  j)ermanent 
chorion.'^  At  first  the  embryo  is  connected  with  the  vascular  chorion 
by  two  arteries  and  two  veins.  The  two  arteries  persist  as  the  ar- 
teries of  the  umbilical  cord.  One  of  the  two  veins  disappears,  while 
the  other  becomes  enlarged  in  proportion,  and  forms  the  umbilical 
vein. 

With  the  growth  of  the  ovum  its  surface  diminishes  in  vascularity, 
except  in  the  neighborhood  of  the  attachment  of  the  allantoic  vessels, 
at  which  point  the  villi  increase  in  size  and  profusion.  Over  the  rest 
of  the  ovum  the  villi  atrophy  and  disappear.  Thus  the  greater  portion 
of  the  chorion  becomes  smooth,  while  about  one  third  of  its  surface  is 
covered  with  a  thickened,  shaggy  portion,  destined  to  contribute  to 
the  formation  of  the  placenta. 

The  Deciduse. — When  the  ovum  passes  from  the  Fallopian  tubes 
into  the  uterus,  it  finds  the  mucous  membrane  prepared,  by  certain 
changes,  for  its  reception.  These  changes,  as  shown  in  a  specimen  ex- 
amined by  Dr.  Engelmann,f  in  the  first  month  consisted  of  a  ten-fold 
increase  in  thickness  (two  fifths  of  an  inch).  The  tissues  were  intensely 
vascular,  and  the  entire  mucous  membrane  was  thrown  into  convolu- 
tions. The  thickening  was  mainly  due  to  an  increase  in  the  elements 
composing  the  inter-glandular 
connective  tissue.  This  was  more 
especially  the  case  in  the  upper 
layers,  where  the  cells  were  like 
those  of  young  connective  tissue. 
A  soft,  pulpy  state  of  the  mu- 
cous membrane  was  occasioned  Fig.  46.-Formatiorofdecidua,  first  s^^^^ 
by  an  augmented  production  of 

the  amorphous  inter-cellular  substance  which  characterizes  connective 
tissue  in  the  embryonic  state. 

It  is  this  thickened,  vascular,  softened  mucous  membrane  which 
furnishes  the  decidua  vera. 

The  ovum,  soon  after  its  entry  into  the  uterus,  finds  a  bdgment  in 
one  of  the  folds  of  the  decidua  vera.  Tliis  takes  place  usually  in  the 
upper  portion  of  the  uterine  cavity,  upon  the  posterior  wall,  near  one 
of  the  tubal  orifices. 

The  point  of  attachment  between  the  ovum  and  the  decidua  is  dis- 

*  The  outer  portion,  derived  from  the  ectoderm,  furnishes  the  epithelium,  and  is  called 
the  exochorion,  while  the  inner  vascular  surface  furnished  by  the  allantois  is  entitled  the 
emlocJiorion. 

f  Engelmann,  "Mucous  Membrane  of  the  Uterus,"  "Amer.  Jour,  of  Obstet.,"  May, 
1875. 


52 


PHYSIOLOGY  OF  THE  OVUM. 


tinguished  as  the  decidua  serotina.  It  is  physiologically  important  as 
the  site  of  the  placenta. 

The  ovum  is  not  simply  adherent.    It  lies,  as  it  were,  imbedded  in 

the  tumefied  membrane, 
  ^  folds  of  which  grow  up 


the  decidua  vera  and  reflexa  is  filled  by  opaque,  viscid  mucus. 

The  Placenta. — The  villi  which  cover  the  chorion  become  imbedded 
in  the  soft  tissues  of  the  decidua,  and  derive,  by  absorption,  nutritive 
materials  from  the  circulatory  system  of  the  mother.  After  the  for- 
mation of  the  permanent  chorion,  by  the  extension  of  the  allantois  to 
the  inner  surface  of  the  egg,  the  allantoic  vessels  convey  the  absorbed 
materials  directly  to  the  embryo.  At  first,  absorption  takes  place  from 
the  entire  circumference  of  the  chorion,  but  with  the  enlargement  of 
the  ovum  there  ensues  a  thinning  of  the  reflexa,  with  obliteration  of 
its  vessels.  At  the  same  time  the  villi  cease  to  grow  over  that  portion 
of  the  chorion  in  contact  with  the  reflexa,  and  the  whole  process  of 
exchange  between  foetus  and  mother  becomes  concentrated  at  the  de- 
cidua serotina.  At  this  point  the  chorion,  in  place  of  becoming  bare, 
is  covered  with  an  infinite  multitude  of  villi,  which  enlarge,  lengthen, 
and,  by  sending  out  lateral  offshoots,  assume  an  arborescent  appear- 
ance. The  villi  are  arranged  in  tufts,  sixteen  to  twenty  in  number, 
which  together  form  a  soft,  spongy  mass,  and  constitute  the  fetal 
portion  of  the  placenta. 

The  uterine  mucous  membrane,  in  which  the  villi  lie  imbedded, 
contributes  likewise  its  share  to  the  make-up  of  the  completed  pla- 
centa. The  structure  of  this  so-called  maternal  portion  of  the  or- 
gan has  been  the  subject  of  much  difference  of  opinion.  Indeed,  an 
intelligible  idea  of  its  anatomy  can  hardly  be  conveyed  without  a 
preliminary  consideration  of  certain  points  connected  with  its  devel- 
opment. 

*  Leopold,  in  his  account  of  the  uterine  mucous  membrane,  adopts  Reichort's  view  of 
the  formation  of  the  reflexa,  viz.,  that,  owing  to  the  less  rapid  increase  in  the  growth  of 
the  serotina,  the  ovum  becomes  buried  in  the  thickening  of  the  vera. — (  Vide  "  Studien 
Uber  die  Uterusschleimhaut,"  etc.,  "  Arch.  f.  Gynaek.,"  Bd.  xi,  p.  455.) 


The  folds  of  mucous 
membrane  which  inclose 
the  ovum  are  termed  the 
decidua  reflexa. 


around  it  and  finally 
meet  so  as  to  inclose  it 
in  a  cavity  of  its  own, 
shut  off  from  the  gener- 
al cavity  of  the  uter- 


Fig.  47. — Formation  of  decidua  completed,    a,  decidua  re- 
flexa ;  6,  decidua  vera ;  c,  decidua  serotina. 


The  space  between 


DEVELOPMENT  OF  THE  OVUM. 


53 


Thus,  the  villi  are  often  erroneously  described  as  penetrating  direct- 
ly into  the  glandular  structures  of  the  adjacent  uterine  mucous  mem- 
brane. Professor  Turner  has,  however,  conclusively  shown  that,  in  all 
the  less  complicated  placental  forms  throughout  the  animal  kingdom, 
the  depressions  or  crypts  into  which  the  villi  dip  occupy  the  soft, 
pulpy,  interglandular  tissues.  Engelmann  further  draws  attention  to 
the  large  size  of  the  terminal  sprouts  of  the  villi  in  the  human  placenta, 
which  would  render  their  entrance  into  the  glandular  tubules,  unless 
by  a  mere  exceptional  chance,  a  mechanical  impossibility.  Moreover, 
Friedlander  *  has  demonstrated,  as  will  be  again  noted  hereafter,  the 
persistence  of  the  enlarged  flattened  glands  in  the  serotina  even  after 
the  separation  of  the  placenta  at  childbirth.  It  may  be  deemed, 
therefore,  as  fairly  settled  that  the  maternal  portion  of  the  placenta  is 
derived  from  the  tissues  occupying  the  spaces  between  the  glands,  and 
not  from  the  glands  themselves. 

In  the  mare,  the  relations  of  the  villi  to  the  uterine  mucosa  are  of 
the  simplest  character.  With  a  little  force  it  is  possible  to  draw  the 
villi  from  the  crypts,  which,  on  vertical  section,  are  seen  to  be 
cup-like  depressions  between  the  glands.  The  crypts  are  surrounded 
by  a  dense  capillary  plexus,  and  are  lined  by  epithelial  cells.  The 
epithelial  cells  are  partly  columnar,  like  those  covering  the  mucous 
membrane  of  the  uterus  in  the  unimpregnated  state,  while  others 
are  so  swollen  out  that  their  length  but  little  exceeds  their  breadth^ 
while  others  are  of  irregular  shape.  Transitional  forms  prove  the 
derivation  of  the  irregularly  shaped  cells  from  ordinary  columnar  epi- 
thelium, f 

In  the  arrangement  just  described,  it  will  be  seen  that  the  villi, 
containing  the  vessels  communicating  with  the  foetus,  dip  into  crypts 
in  the  uterine  mucous  membrane.  The  crypt-walls  are  highly  vascu- 
lar, and  are  lined  with  epithelium.  There  is,  therefore,  no  direct  com- 
munication between  the  fetal  and  maternal  blood-vessels.  The  crypts, 
however,  elaborate  a  secretion,  termed  by  Haller  uterine  milk,  which 
contains  fatty,  saline,  and  albuminous  matters  dissolved  in  water.  The 
uterine  milk  is,  therefore,  well  qualified  to  serve  as  a  nutrient  mate- 
rial, and  is  without  doubt  absorbed  by  the  villi  for  the  benefit  of  the 
foetus.  X 

*  Friedlander,  "  Untersuchungen  iiber  den  Uterus,"  18*70 — Ueber  die  Innenflacbe 
des  Uterus  post  partum,  "Arch.  f.  Gynaek.,"  Bd.  ix,  p.  22,  1876.  Friedlander's 
observations  have  been  confirmed  by  Kundrat  and  Engelmann,  Langhans,  and  Leo- 
pold. 

f  Professor  Turner,  "  The  Structure  of  the  Placenta,"  "  Jour,  of  Anat.  and  Physi- 
ol.," vol.  X,  p.  136. 

X  The  uterine  milk  can  not  be  obtained  from  the  placenta  of  the  mare  unmixed  with 
the  secretions  from  the  uterine  glands.  The  analyses  of  Professors  Prcvost,  Schloss- 
bcrger,  and  Gamgee  were  made  upon  a  fluid  derived  from  polycotyledonous  placentae. 
— (  Vide  "Structure  of  the  Placenta,"  p.  176.) 


54 


PHYSIOLOGY  OF  THE  OVUM. 


In  the  cat,  the  villi  of  the  chorion  have  the  form  of  broad,  sinuous 
leaflets,  which,  about  the  completion  of  one  half  the  period  of  gesta- 
tion, are  so  interlocked  with  the  crypts  that  the  two  surfaces  can  not 
be  disengaged  from  one  another.  Vertical  sections  show  that  the  walls 
of  the  crypts  closely  follow  the  sinuosities  of  the  villi  in  such  wise  as 
to  form  an  intimate  investment  for  them.  Injections  of  the  maternal 
capillaries  show  them  to  be  dilated  to  two  or  three  times  the  size  of 
the  capillaries  in  the  fetal  villi.* 

In  the  human  placenta  the  relations  of  the  villi  to  the  uterine  mu- 
cous membrane  differ  somewhat  at  different  stages  of  development. 
Thus,  at  first,  the  empty  cylindrical  villi  simply  sink  into  the  soft, 
pulpy,  interglandular  spaces.  Next,  as  the  villi  sprout  and  become  vas- 
cular and  arborescent,  projections,  formed  from  the  proliferation  of 
the  superficial  portion  of  the  serotina,  grow  around  the  offshoots  and 
branching  processes.  At  this  time  we  distinguish  in  the  placenta  a 
fetal  portion,  the  placenta  fmtalis,  composed  of  the  villous  tufts  of  the 
ovum,  and  a  uterine  portion,  the  placenta  uterina,  derived  from  the 
tissues  of  the  serotina. 

In  the  third  and  fourth  months  the  union  of  the  fetal  and  maternal 
tissues  is  very  intimate.  But,  subsequently,  the  growth  of  the  uterine 
tissue  does  not  keep  pace  with  that  of  the  villi,  so  that  the  mature 
placenta  is  almost  altogether  a  fetal  organ.  A  layer  of  uterine  mu- 
cosa, not  exceeding  of  an  inch  in  thickness,  covers  the  surface  of 
the  placenta  after  delivery.  Between  the  cotyledons,  however,  thin 
partitions  from  the  serotina  extend  downward  for  a  considerable 


Fig.  48. — Diagram  showing  the  branching  of  the  villi  and  the  connection  of  the  larger  trunks 
with  the  placenta,  a,  chorion  ;  J,  primary  trunk,  with  radiate  branches  (c) ;  the  ter- 
tiary branches,  which  either  directly,  or  after  previous  division  (c?'),  penetrate  the  pla- 
centa materna  (/).  The  free  terminal  tufts  (e)  are  indicated  only  at  a  few  points. 
(Langhans.) 

distance,  though  never,  except  near  the  borders,  as  far  as  the  cho- 
rion. 

Sections  through  the  hardened  placenta  show  that  the  main  villous 
trunks  divide  at  a  short  distance  from  the  chorion.    The  secondary 
branches  assume  a  radiate  direction,  from  which  proceed  tertiary 
*  Turner,  op.  cit.^  pp.  155,  156. 


DEVELOPMENT  OF  THE  OVUM. 


55 


branches,  which  terminate  in  club-shaped  extremities  and  bury  them- 
selves in  the  serotina.  From  these  tertiary  branches  fine  lateral  ones, 
having  a  dendritic  arrangement,  are  given  off,  and  fill  the  spaces  be- 
tween the  tertiary  trunks. 

Many  of  these  lateral  tufts  are  attached  directly  to  the  serotina, 
and  fill  up  in  part  the  interval  between  the  larger  radiate  branches  ; 
others,  again,  float  freely  in  the  blood-currents  derived  from  the  ma- 
ternal vessels.* 

The  precise  origin  and  nature  of  the  vascular  spaces  between  the 
villi  have  been  a  prolific  subject  of  discussion.  In  the  early  months, 
we  saw,  the  serotinal  projections  extended  deep  down  between  the 
villi,  and  contained  largely  dilated  capillaries ;  and  yet  afterward 
every  trace  of  these  vessels  is  found  to  have  disappeared  throughout 
the  entire  placenta,  except  in  the  thin  layer  of  the  placenta  uterina, 
where  the  endothelium,  or  inner  lining,  may  still  be  detected.  The 
most  probable  supposition  is,  that  the  vessels  have  become  eroded 
and  finally  destroyed  by  the  growth  of  the  villi,  leaving  the  blood 
to  flow  unimpeded  through  the  intervillous  spaces.  A  delicate  layer 
of  epithelium  may,  indeed,  be  found  upon  the  villous  trunks  and 
tufts  ;  but  tJiese,  it  is  sufficiently  established,  belong  to  the  villi, 
aad  are  derived  from  the  exochorion.  f  Whether  these  cells  essen- 
tially modify  the  interchange  between  the  fetal  and  maternal  cir- 
culations, can  only  be  a  matter  of  conjecture.  The  fact  that  cer- 
tain medicinal  substances,  such  as  iodide  of  potassium  and  salicylic 
acid,  when  administered  during  the  latter  days  of  pregnancy,  may  be 
found  in  the  blood  and  secretions  of  the  foetus,  whereas  others,  as 
woorari  and  perhaps  mercury,  have  not  been  so  found,  renders  some 
action  on  the  part  of  the  cells,  aside  from  simple  osmosis,  at  least 
probable.  I 

The  Structure  of  the  Fully-developed  Placenta.— The  placenta,  after 
its  removal  from  the  body,  is  found  to  be  a  soft,  spongy  mass,  of  a 
somewhat  oval  shape.  It  measures  upward  of  seven  and  a  half  inches 
in  its  longest  diameter,  is  from  two  thirds  to  an  inch  in  diameter  at 
the  point  of  insertion  of  the  funis,  and  weighs  about  sixteen  ounces. 
Its  internal  surface  is  smooth,  and  is  covered  by  the  amnion,  through 
which  the  vessels,  communicating  with  those  of  the  funis,  can  be  seen 
m  their  distribution  over  the  surface  of  the  organ,  previous  to  plung- 

*  Langhans,  "Zur  Kenntniss  der  menschlichen  Placenta,"  "Arch.  f.  Gynaek.,"  Bd.  i, 
1810,  p,  iill ;  vide,  also,  Kollikeh,  "  Entwlckelungs-Geschichte  "  ;  Leopold,  "Der  Bau 
der  Placenta,"  "Arch.  f.  Gynaek.,"  Bd.  xi,  1877,  p.  443. 

f  KoLLiKER,  "  Entwickclungs-Geschichte,"  2te  Auflage,  p.  333  ;  Leopold,  "  Der  Bau 
der  Placenta,"  "  Arch.  f.  Gynaek  ,"  Bd.  xi,  p.  467. 

X  Vide  Fehling,  "Zur  Lehrc  der  Stoffwechsel,"  "Arch.  f.  Geburtsk.,"  Bd.  ix,  p.  313; 
Beneke,  "Ztschr.  f.  Geb.- und  Frauenkrankheiten,"  Bd.  i,  p.  477 ;  Gusserow,  "Arch, 
f.  Geburtsk.,"  Bd.  iii,  p.  241 ;  Schauenstien  und  Spaeth,  "  Jahrb.  der  Kinderheilk.," 
2te8  Jahrg.,  p.  13. 


56 


PHYSIOLOGY  OF  THE  OVUM. 


ing  into  the  tissues  beneath.  The  uterine  surface  has  a  peculiar,  gran- 
ular feel,  and  is  divided  into  a  number  of  lobes,  corresponding  to  the 
fetal  tufts  or  cotyledons  already  described.  It  is  covered  with  a  soft, 
thin  membrane,  which  sends  septa  or  partitions  in  between  the  cotyle- 
dons. This  membrane  is  simply  the  product  of  the  surface  layer  of 
the  serotina. 

Curled  arteries  from  the  uterus  penetrate  the  cotyledons,  and  con- 
vey the  maternal  blood  into  the  spaces  or  lacunae  between  the  fetal 


AR. LAYER. 

Fig.  49. — Diagram  of  uterus  and  placenta  in  the  fifth  month.    Ch,  chorion  ;  Am,  amnion; 
P,  villi ;  Z,  lacunae ;  *i>,  serotina  ;  AB,  areolar ;  V,  small  arteries.  (Leopold.) 


tufts.  Through  these  spaces  the  blood  flows  m  a  sluggish  current, 
and  is  conveyed  back  to  the  uterus  by  the  coronary  vein  upon  the  mar- 
gin of  the  placenta,  and  by  means  of  sinuses  situated  in  the  septa  be- 
tween the  cotyledons,  and  continuous  with  the  venous  sinuses  of  the 
uterine  walls.*  The  fetal  tufts  which  thus  bathe  in  the  mother's 
blood  receive,  through  the  umbilical  arteries,  the  blood  which  comes 
from  the  foetus  darkened  with  carbonic  acid.  In  the  ultimate  rami- 
fications of  the  villi,  the  arteries  communicate  by  an  arch  or  loop  with 
a  corresponding  branch  of  the  umbilical  vein,  which  returns  to  the 
child  red,  arterialized  blood,  f 

*  For  affirmative  evidence  of  the  existence  of  placental  lacunae,  vide  Professc 
Turner,  "Structure  of  the  Human  Placenta,"  "Jour,  of  Anat.  and  Physiol.,"  vol. 
vii,  p.  120.  So,  too.  Professor  Dalton's  ingenious  inflation  of  the  intervillous  spaces 
with  air,  "  Treatise  on  Human  Physiology,"  1867,  p.  615.  For  objections,  the  elaborate 
paper  of  Braxton  Hicks,  in  the  London  "  Obstet.  Trans.,"  vol.  xiv,  deserves  careful 
perusal. 

f  Vide  experiments  of  Zweifkl,  "  Die  Respiration  des  Foetus,"  "  Arch.  f.  Gynaek.," 
Bd.  ix,  p.  292.    See,  also,  B6rard,  t.  iii,  p.  422,  experiments  of  Legallois. 


DEVELOPMENT  OF  THE  OVUM. 


57 


But  the  placenta  is  not  simply  a  respiratory  organ.  The  rapid  de- 
Yclopment  of  the  ovum,  from  a  simple  cell  of  microscopic  size  to  the 
proportions  of  the  infant  at  birth,  argues  as  surely  that  the  relations  of 
the  blood-currents  in  the  placenta  enable  the  foetus  to  derive  from 
the  mother  all  the  proximate  principles  required  for  the  building 
up  of  tissue,  the  differentiation  of  organs,  and  the  performance  of 
function. 

Then,  too,  the  foetus  has  been  shown  to  have  a  temperature  of  its 
own,  somewhat  higher  than  that  of  the  mother.*  This  production  of 
heat  is  necessarily  attended  with  destruction  of  tissue.  Of  this  there 
is  evidence  in  the  presence  of  urea  in  the  bladder  and  the  amniotic  fluid. 
There  can  be  little  question,  however,  but  that  the  placenta  furnishes 
the  chief  channel  through  which  the  devitalized  products  are  dis- 
charged. 

The  Formatioj^  of  the  Umbilical  Cord. 

To  understand  the  structure  of  the  cord,  it  is  well  to  bear  in  mind 
the  various  particulars  connected  with  its  development.  At  the  time 
when  the  allantois  first  appears  as  a  sac-like  projection  from  the  intes- 
tine, the  embryo  is  hardly  more  than  an  appendage  to  the  umbilical 
vesicle.  The  larger  size  of  the  latter  directs  the  allantois  over  the 
posterior  extremity  of  the  foetus.  By  its  growth  and  extension,  the 
allantois  reaches  the  chorion,  and  forms  a  sort  of  pedicle,  by  means  of 
which  a  vascular  communication  is  established  between  the  embryo 
and  the  periphery  of  the  ovum.  This  pedicle  is  the  first  indication  of 
the  umbilical  cord.  Its  vessels  become  reduced  to  two  arteries,  the 
umbilical  arteries,  and  a  single  vein,  the  umbilical  vein.  Meantime, 
the  umbilical  vesicle  diminishes  in  size,  and  finally  shrinks  to  a  mere 
thread.  The  amnion  fills  with  fluid,  exuded  probably  from  the  body 
of  the  foetus,  and  continues  to  expand,  so  that  often  by  the  end  of  the 
second  month  it  comes  in  contact  with  the  chorion,  f  In  this  way,  it 
forms  a  reflection  over  the  pedicle  of  the  allantois,  which  it  invests 
like  the  finger  of  a  glove.  Finally,  the  structure  of  the  cord  is  com- 
pleted by  the  formation  of  an  elastic  substance,  termed  the  gelatine  of 
Wharton,  which  consists  of  connective-tissue  elements  inclosing  large 
spaces  containing  amorphous  matter.  The  gelatine  of  Wharton  func- 
tionally serves  to  protect  the  vessels  of  the  cord  from  compression. 
It  is  formed  by  hypergenesis  from  the  outer  layers  of  the  amnion 
and  the  allantois,  both  of  which  are  derived  from  the  intermediate 
layer,  described  in  the  development  of  the  foetus  {vide  p.  74).  The 

*  Wdrster,  "Ueber  die  Eigcnwarme  der  Neugcbornen,"  "  Berl.  klin.  Woch.,"  Nr.  87, 
1869  ;  Alexeef,  "  Ueber  die  Temperatur  des  Kindes  im  Uterus,"  "  Arch.  f.  Gynaek,"  Bd. 
X,  p.  14L 

f  Fic/e  Hunter's  "Gravid  Uterus,"  plate  xxxiii,  Fig.  2  ;  Ecker,  "  Icon.  Pliysiolog.," 
plate  xxxiii,  Fig.  7. 


58 


PHYSIOLOGY  OF  THE  OYUM. 


intermediate  layer  furnishes,  likewise,  the  connective  tissue  of  the 
body. 

The  fully-developed  cord  consists,  therefore,  of  a  sheath  from  the 
amnion,  the  gelatine  of  Wharton,  the  umbilical  vein  and  arteries,  and 
traces  of  the  umbilical  vesicle,*  and  the  pedicle  of  the  allantois.f  It 
averages  twenty  inches  in  length,  though  it  has  been  observed  as  long 
as  seventy-five  inches,  and  as  short  as  three  inches.  J;  A  long  cord 
predisposes  to  the  formation  of  coils  about  the  neck,  body,  and  limbs 
of  the  foetus.  It  is  usually  of  about  the  size  of  the  little  finger, 
but  is  very  variable,  its  circumference  depending  chiefly  upon  the 
quantity  of  the  gelatine  of  Wharton.  The  arteries  are  so  twisted 
as  to  form  spiral  turns  around  the  vein,  and,  owing  to  the  superior 
length  of  the  right  artery,  in  most  cases  in  the  direction  from  right 
to  left.  As  an  anatomical  peculiarity,  may  be  mentioned  the  fact 
that  the  walls  of  the  arteries  are  only  slightly  thicker  than  those  of 
the  vein. 

The  Amniotic  Fluid. — The  origin  of  the  amniotic  fluid  in  the  earlier 
months  of  gestation  is  not  known,  the  most  probable  suggestion  being 
that  it  is  simply  e-xuded  from  the  tissues  of  the  foetus.  After  the  for- 
mation of  the  placenta,  a  capillary  network,  connected  with  the  vessels 
of  the  umbilical  cord,  is  developed  just  beneath  the  amnion  in  that 
portion  of  the  chorion  which  covers  the  placenta.  From  these  vessels 
a  transudation  of  serum  takes  place  into  the  cavity  of  the  amnion.* 
After  the  first  half  of  pregnancy  has  been  reached,  the  capillary  net- 
work disappears.  The  continued  increase  of  fluid  in  the  amnion  in 
the  later  months  of  gestation  is  due  to  the  accumulation  of  urine, 
which  the  foetus  passes  intermittently  during  intra-uterine  existence.  || 
The  composition  of  the  amniotic  fluid  corresponds  to  its  double  origin. 
In  addition  to  water  it  contains  albumen,  urea,  and  the  saline  sub- 
stances wdiich  are  found  in  serum  and  urine.  Its  quantity  varies  usu- 
ally betw  een  one  and  two  pints,  of  which  nearly  one  half  is  contributed 
during  the  last  three  lunar  months.^ 

*  ScHULTZE,  '*  Das  Nabelblaschen,  ein  constantes  Gebilde,"  etc.,  Leipsic,  1861. 
f  Ahlfeld,  "Die  Allantois  des  Menschen,"  "  Arch.  f.  Gynaek.,"  Bd.  x,  p.  81. 
X  "  Lehrbuch  der  Geburtshiilfe,"  von  Otto  Spiegelbcrj.'-,  p.  82. 

*  JuNGBLUTH,  "  Bcitrag  zur  Lehre  vom  Frucbtwasser,"  Inaug.  Dissert.,  Bonn,  1869. 

II  GussEROW,  "  Zur  Lehre  vom  Stoifwechsel  des  Foetus,"  "  Arch.  f.  Gynaek.,"  Bd.  iii, 
p.  268,  269.  Prochownick,  "  Beitragc  zur  Lehre  vom  Frucbtwasser  und  seiner  Entste- 
bung,"  "  Arch.  f.  Gynaek.,"  Bd.  xi,  p.  304. 

^  GussKROW,  I.  c,  p.  269. 


DEVELOPMENT  OF  THE  F(ETUS. 


59 


CHAPTER  III. 

DEVELOPMENT  OF  THE  FCETUS. 

Area  genninativa. — Primitive  trace. — Dorsal  plates. — Tuba  medullaris, — Cerebral  vesi- 
cles.— Chorda  dorsalis. — Vertebral  plates. — Abdominal  plates. — Central  plates. — De- 
velopment of  the  bony  skeleton. — Development  of  the  intestine,  face,  lungs,  liver, 
pancreas,  bladder,  heart. — Development  of  foetus  in  successive  months  of  preg- 
nancy.— Foetus  at  term. — Fetal  cranium. — The  attitude,  position,  and  presentation 
of  the  foetus. 

The  study  of  fetal  development  belongs  properly  to  works  on 
physiology,  and  to  them  the  reader  is  referred  for  completeness  of 
detail.  The  following  enumeration  of  the  principal  facts  in  embryol- 
ogy has,  however,  been  introduced  by  the  writer,  in  the  belief  that  it 
will  be  useful  for  reference  to  both  the  student  and  practitioner  of 
obstetrics. 

First  in  order  will  be  remembered  the  segmentation  of  the  ovum, 
the  formation  of  the  blastodermic  membrane,  and  the  development  of 
the  area  germinativa  by  the  accumu- 
lation of  cells  at  a  limited  point 
upon  the  inner  surface  of  the  blasto- 
dermic membrane.  An  inner  blas- 
todermic layer  is  formed  by  the  pe- 
ripheral extension  of  the  cells  at  the 
area  germinativa.  Between  the  out- 
er and  inner  layers  a  third  or  inter- 
mediate layer  makes  its  appearance. 
This  third  layer  is  confined  to  the 
area  germinativa.  Subsequently  its 
peripheral  portions  further  separate 
into  two  strata.  In  vertebrate  ani- 
mals a  union  of  these  separate  lay- 
ers exists  at  the  point  at  which  the 
spinal  column  is  to  be  developed. 
At  first  the  area  germinativa  is  a 
round  disk  with  a  clear  center,  the 
area  pellucida,  and  a  dark  border, 
the  area  opaca,  but  afterward  be- 
comes of  an  oval  shape.  In  the 
middle  of  the  area  pellucida  a  dark 
oval  spot,  termed  the  embryonic 
spot,  is  formed  by  the  rapid  multiplication  of  cells,  and  is  directly 
concerned  in  the  formation  of  the  embryo. 

In  the  middle  of  the  embryonic  spot  there  suddenly  appears  the 
primitive  trace,  a  furrow  bordered  by  two  ridges,  the  dorsal  plates, 


Fig.  50. — Area  germinativa,  from  the  ovum 
of  a  rabbit,  enlarged  about  ten  diame- 
ters. On  account  of  the  dark  back- 
t^round  the  semi-ti-ansparcnt  area  pel- 
lucida looks  dark,  whereas  the  area 
opaca  and  the  embryonic  spot  both 
appear  white,  Tlie  dark  line  in  the 
center  is  the  primitive  trace.  ( Haeck- 
el.) 


60 


PHYSIOLOGY  OF  THE  OVUM. 


which  finally  meet  above  so  as  to  inclose  a  cylindrical  space,  viz.,  the 
tubus  medullaris.  In  this  closed  tube  is  developed  the  nervous  system, 
at  first  in  the  form  of  a  cord,  uniform  in  size.  Soon,  however,  a  dilata- 
tion takes  place  in  the  anterior  extremity,  at  first  single,  but  after- 
ward by  two  annular  constrictions,  divided  into  three  communicating 
compartments  termed  the  cerebral  vesicles.    The  first  of  these  is 


Fig.  51. — Development  of  the  nervous  system  of  the  chick  (Lonsret).  A,  the  two  primitive 
halves  of  the  nervous  system  twenty -four  hours  after  incubation  ;  B,  the  same  tliirty-six 
hours  after ;  C,  the  same  at  a  more  advanced  stage,  c,  the  two  primitive  halves  of  the 
vertebrae;  anterior  dilatation  of  the  neural  canal ;  h,  lumbar  enlargement;  1,  2,  3^  an- 
terior, middle,  and  inferior  cerebral  vesicles ;  a,  slight  flattening  of  the  anterior  vesicle  ; 
o,  formation  of  the  ocular  vesicles. 

further  subdivided  into  two  compartments  to  form  respectively  the 
cerebral  hemispheres  and  the  optic  thalami ;  the  second  primitive 
vesicle  is  developed  into  the  tubercula  quadrigemina,  or  centers  of 
vision.  The  third  or  posterior  primitive  vesicle  is  divided  into  two 
secondary  vesicles,  the  anterior  to  form  the  cerebellum,  the  posterior 
to  form  the  medulla  oblongata,  and  the  pons  Varolii  (Flint). 


:A'^  B 


Fig.  52. — Development  of  spinal  cord  and  brain  of  human  subject  (Longet).  A,  brain  and 
spinal  cord  at  seventh  week.  B,  more  advanced  stage  ;  h,  spinal  cord  ;  d,  enlargement  of 
the  spinal  cord  with  its  anterior  curvature;  <?,  cerebellum;  tubercula  quadrigemina; 
/,  optic  thalamus ;  <7,  cerebral  hemispheres.  C,  brain  and  spinal  cord  at  eleventh  week, 
as  in  foregoing  ;  o,  optic  nerve  of  the  left  side.    C,  vertical  section  of  the  preceding. 


Lumbar  and  brachial  enlargements  likewise  form  at  the  points  at 
which  the  nerves  are  given  off  to  the  upper  and  lower  extremities. 

In  the  very  earliest  stages  of  development,  there  appears,  just  be- 
neath the  primitive  groove,  a  cylindrical  body,  tapering  at  both  extrem- 


DEVELOPMENT  OF  THE  FCKTUS. 


61 


Fig.  53. — Transverse  section  through  the  em- 
bryo of  a  chick  at  the  end  of  the  first  day 
of  incubation  (magnified  twenty  diame- 
ters), dorsal  palates  ;  ch^  chorda  dor- 
salis  ;  ■y,  vertebral  chords  ;  a  abdominal 
plates. 


ities,  of  a  cartilage-like  consistence,  and  extending  the  entire  length 
of  the  embryo.  This  organ  is  termed  the  chorda  dorsalis  {cli,.  Fig. 
53).  It  is  a  temporary  structure,  but  of  great  interest  from  its  sus- 
taining an  intimate  relation  in  the  vertebrate  classes  to  the  produc- 
tion of  the  bony  skeleton. 

Upon  either  side  of  the  chorda  dorsalis,  and  running  parallel  to  it, 
two  longitudinal  masses  {vide  Fig.  53)  are  separated  off  from  the  cen- 
tral portions  of  the  intermediate 

layer.  They  are  sometimes  termed  ^ 
the  primitive  vertebral  plates, 
though  they  are  more  properly 
columns.  They  are  concerned 
in  the  formation  of  the  vertebrae, 
the  muscles  of  the  back,  and  the 
origin  of  the  spinal  nerves.  The 
outer  strata  of  the  two  peripheral 
portions  of  the  intermediate  layer 
serve  to  close  in  the  great  cavities  of  the  body,  and  hence  are  termed 
the  abdominal  plates  {a. p.). 

In  its  earlier  stages  the  anterior  half  of  the  embryo  is  occupied  by 
the  cerebral  vesicles.  At  this  portion,  the  division  into  vertebral  and 
abdominal  plates  does  not  take  place.  The  intermediate  layers,  here 
termed  the  cerebral  plates,  fold  together  over  the  vesicles,  and  invest 
them  with  a  simple  membranous  capsule,  from  which  are  derived  the 
bones,  the  muscles,  and  the  integuments  of  the  head. 

In  the  posterior  half  of  the  embryo,  the  vertebral  plates,  soon  after 
their  formation,  separate  into  a  number  of  cube-shaped  segments 
(C,  Fig.  51).  These  close  together  front  and  rear  around  the  cord, 
to  form  the  primitive  verteirm.  Those  portions  of  the  vertebral  plates 
which  unite  beneath  the  spinal  cord  include  between  their  borders 
the  chorda  dorsalis.  Around  the  chorda  dorsalis  as  a  center  is  devel- 
oped the  cartilage  from  which  are  formed  the  bodies  of  the  vertebrae. 
The  chorda  dorsalis  for  the  most  part  disappears  as  the  bony  frame- 
work is  developed,  so  that  at  birth  only  a  trace  of  its  earlier  existence 
is  to  be  recognized  in  the  intervertebral  cartilages. 

The  spinal  column  is  formed  from  the  inner  portion  only  of  the 
vertebral  plates.  The  outer  portions,  we  have  seen,  form  the  dorsal 
muscles  and  the  roots  of  the  spinal  nerves.  If  the  vertebral  plates  do 
not  close  over  the  dorsal  aspect  of  the  foetus,  the  bony  rings  which 
include  the  spinal  canal  remain  incomplete.  When,  as  sometimes 
happens,  from  arrest  of  development,  this  condition  exists  at  birth, 
a  sac-like  protrusion  of  the  membranes  and  cord  takes  place,  consti- 
tuting the  affection  known  as  spina  Ufida. 

While  these  changes  are  taking  place  upon  the  upper  aspect  of 
,the  embryo,  a  shallow  groove  appears  just  beneath,  and  parallel  to,  the 


62 


PHYSIOLOGY  OF  THE  OVUM. 


chorda  dorsalis.  At  this  point  the  two  inner  layers — inner  blasto- 
dermic layer  (entoderm)  and  inner  stratum  of  the  intermediate  layer 
(mesoderm) — close  laterally,  and  from  front  to  rear,  so  as  to  form  a 
cylindrical  tube  with  blind  extremities.  This  tube,  the  tubus  intes- 
tinalis,  still,  however,  possesses  an  open  communication  with  the  um- 
bilical vesicle,  which  at  this  time  is  very  large.  But  afterward,  as  the 
embryo  increases  in  size,  the  canal  becomes  obliterated,  and  the  um- 
bilical vesicle,  whjch  has  ceased  to  be  of  physiological  importance, 
hangs  from  the  embryo  by  an  imperforate  cord.  From  the  tubus 
intestinalis  are  derived  all  the  viscera  of  the  pleuro-peritoneal  cav- 
ity, with  the  exception  of  those  connected  with  the  genito-urinary 
system. 

The  openings  at  the  mouth  and  anus  into  the  intestine  are  the  result 
of  secondary  processes.  The  oral  orifice  begins  as  a  pit-like  depres- 
sion in  the  membranous  envelope  covering  the  head.  The  depression 
continuously  deepens,  until  it  finally  comes  in  contact  with  the  upper 
end  of  the  intestine.  Then  absorption  of  the  intervening  tissues  takes 
place.  The  intestine,  lined  by  the  internal  blastodermic  membrane, 
unites  w^ith  the  external  layer.  Even  in  adult  life  the  sharp  distinc- 
tion between  the  epithelia  of  the  buccal  cavity  and  the  oesophagus 
points  to  the  difference  in  origin  of  their  respective  mucous  mem- 
branes. By  a  similar  process  the  anus  is  produced,  and  a  communi- 
cation formed  with  the  lower  extremity  of  the  intestine.  When  from 
arrest  of  development  the  anal  depression  does  not  occur,  or  does  not 
reach  the  intestine,  the  malformation  known  as  imperforate  anus  is 
produced. 

In  the  rear  of  the  buccal  cavity,  and  upon  each  side  of  the  neck, 
four  slit-like  openings  make  their  appearance,  which  possess  an  in- 
terest from  the  fact  that,  though  temporary  in  the  higher  vertebrates, 
and  devoid  of  physiological  importance,  they  represent  permanent 
structures  in  fishes,  viz.,  the  branchiae,  or  organs  of  respiration.  These 
openings  are  termed  the  visceral  clefts.  They  include  between  them 
four  sickle-shaped  processes  termed  the  visceral  arches. 

The  buccal  cavity  is  at  first  a  large  orifice,  or  cloaca,  communicating 
with  the  anterior  extremity  of  the  intestine.  But  at  a  very  early 
period  there  likewise  appear,  in  the  frontal  region  of  the  embryo,  two 
funnel-shaped  depressions  termed  the  nasal  fossm,  which  constitute 
the  first  indications  of  the  olfactory  organs.  The  nasal  fossae  are  at 
first  widely  separated  from  one  another,  and  do  not  communicate  with 
the  oral  cavity.  In  the  closure  of  the  latter  to  form  the  mouth,  a 
projection,  termed  the  frontal  or  intermaxillary  process,  is  pushed 
downward  from  the  frontal  wall.  From  the  right  and  left  lower 
borders  of  the  intermaxillary  process  two  secondary  minor  processes, 
termed  the  incisor  processes,  form,  which  bound  the  inner  surface  of 
the  nasal  fossae.    At  the  same  time,  two  offshoots  from  the  frontal  wa^*^ 

) 


DEVELOPMENT  OF  THE  FCETUS. 


63 


curl  aroiiTid  the  outer  surface  of  the  fossae.    In  this  way,  in  the  place 
of  the  nasal  fossae,  two  grooved  canals  are  produced,  open  below, 
which  lead  directly  into  the  oral 
cavity.    The  growth  of  the  nasal 

offshoots  gives  to  the  intermax-  .  \ 

illary  process  a  split  or  notched 
appearance. 

The  upper  jaw  is  completed 
by  the  pushing  out  from  the 
central  ends  of  the  maxillary 
(upper  visceral)  arch  of  two  con- 
ical growths  (5,  Fig.  54),  which 
approach  one  another  in  the  me- 
dian line.  As  they  do  so  they 
include  between  them  the  inter- 
maxillary process,  and  furnish 
the  floors  of  the  olfactory  canals. 
The  lateral  pressure  brings  into 
apposition  the  divergent  halves 
of  the  notched  surface  of  the 

intermaxillary  process.    The  na-  -  ^ 


11 . 

8 

Fig.  54. — Human  embryo  between  the  twenty- 
fifth  and  twenty-ei£,'ht]i  days,  showing  the 
visceral  arches  (7,  8,  9).  (Coste.) 


sal  passages,  which  at  first  ^vere 
widely  apart,  come  into  close 
contact.     The  eyes,  too,  which 
were  situated  at  the  sides  of  the  head,  move  to  the  front  until  their 
axes  look  directly  forward,  and  parallel  to  one  another. 

The  intermaxillary  bone,  to  which  subsequent  to  dentition  the 
upper  central  incisor  teeth  are  attached,  is  derived  from  the  intermax- 
illary process.  The  superior  maxillary  processes  not  only  furnish  the 
two  superior  maxillae,  but  the  material  from  which  tlie  sphenoid  and 
palatine  bones  are  derived. 

Hare-lip  results  from  an  arrest  in  the  development  process  just 
described.  The  lip,  like  the  jaw,  is  formed  by  the  union  of  the  inter- 
maxillary with  the  superior  maxillary  processes.  In  case  of  the  failure 
of  either  superior  maxillary  process  to  unite  with  the  intermaxillary 
process,  a  fissure  is  formed  to  the  side  of  the  median  line.  This  is 
termed  simjle  hare-lip.  An  arrest  of  development  upon  both  sides 
gives  rise  to  douhle  hare-lip.  Sometimes  the  separation  is  not  confined 
to  the  lip,  but  extends  to  the  bony  structures  of  the  jaw.  The  case  is 
then  said  to  be  one  of  complicated  hare-lip. 

The  roof  of  the  mouth,  oy  palatine  arch,  which  separates  the  mouth 
from  the  nasal  passages,  is  derived  from  two  horizontal  phites,  spring- 
ing from  the  inner  surfaces  of  the  superior  maxillary  processes.  These 
)lates  approach  one  another,  and  finally  fuse  together  in  the  median 
jine.    An  arrest  of  development  upon  one  side  gives  rise  to  cleft  palate. 


64 


PHYSIOLOGY  OF  THE  OVUM, 


The  vomer,  which  forms  the  vertical  partition  of  the  nares,  is  de- 
rived from  the  intermaxillary  process. 

With  the  formation  of  the  superior  maxillary  process,  the  residue 


Fig.  55. — Moutli  of  embryo  of  thirty-five  days  (Coste).  1,  frontal  process  widely  sloped  at 
its  inferior  portion  ;  2,  2,  incisor  processes  produced  by  this  sloping ;  3,  3,  nostrils  ;  4, 
lower  lip  and  maxilla,  formed  by  the  union  of  the  inferior  maxillary  process ;  5,  5,  supe- 
rior maxillary  processes  ;  6,  mouth ;  7,  first  appearance  of  closure  or  nasal  fossae ;  8,  8, 
first  appearance  of  the  two  halves  of  the  palatine  arch;  9,  tongue;  10,  10,  eyes;  11,  12, 
13,  visceral  arches. 

Fig.  56. — Mouth  of  embryo  of  forty  days  (Coste).  1,  first  appearance  of  the  nose  ;  2,  2,  first 
appearance  of  alee  of  nose  ;  3,  closure  beneath  the  nose  ;  median  portion  of  upper  lip 
formed  by  the  union  of  the  incisor  processes,  a  little  notch  in  the  median  line  indicating 
the  primitive  separation  of  the' two  processes  ;  5,  5,  superior  maxillary  processes  ;  G,  6, 
groove  for  the  development  of  the  lachrymal  sac  and  the  nasal  canal ;  7,  lower  lip  ;  8, 
inouth ;  9,  9,  the  two  lateral  halves  of  the  palatine  arch. 

of  the  upper  visceral  arch  {vide  4,  Fig.  55)  becomes  known  as  the 
inferior  maxillary  process.  From  its  base  are  derived  two  little  bones 
of  the  ear,  viz.,  the  malleus  and  incus.  The  outer  portion  is  con- 
verted into  a  cartilaginous  band,  termed  the  cartilage  of  Meckel,  which 
unites  with  its  neighbor  of  the  opposite  side.  Upon  the  outer  surface 
of  the  cartilage  of  Meckel  is  formed  the  permanent  structure  of  the 
lower  jaw. 

From  the  second  visceral  arch  are  produced  the  stapes,  the  styloid 
process  and  ligament,  and  the  lesser  cornua  of  the  hyoid  bone.  The 
third  arch  forms  the  body  and  greater  cornua  of  the  hyoid.  The 
fourth  arch  in  the  embryo  appears  to  be  a  purely  rudimentary  organ, 
which  docs  not  develop  into  permanent  structures. 

The  lungs  are  derived  from  the  anterior  portion  of  the  intestinal 
tube.    At  first  they  consist  of  a  single  small  sac  which  grows  fro' 
the  tube  just  posterior  to  the  visceral  arches.    Afterward  the  sac  "  ^ 


DEVELOPMENT  OF  THE  FCETUS. 


65 


comes  bifurcated  below  and  forms  two  lateral  halves  (A).  Each  half 
divides  and  subdivides  after  the  manner  of  a  racemose  gland  to  form  the 
lung  (C  and  D).    The  upper  portion  of  the  sac  elongates  and  is  de- 


Fio.  57. — Development  of  the  lungs  (Longet).   A ,  B,  development  of  the  lungs,  after  Eathke ; 
C,  D,  histological  development  of  the  lungs,  after  J.  Miiller. 

veloped  into  the  trachea  (B).  From  the  anterior  portion  of  the  intestine 
is  formed  the  oesophagus.  The  opening  of  the  trachea  into  the  oesopha- 
gus becomes  the  rima  glottidis. 

Posterior  to  the  lungs  (passing  from  front  to  rear)  there  forms  a 
spindle-shaped  dilatation  in  the  intestinal  tube.  This  dilatation  is  the 
first  rudiment  of  the  stomach.  Afterward  it  assumes  an  oblique  posi- 
tion by  a  movement  of  the  upper  portion  to  the  left,  and  the  lower 
extremity  to  the  right.  By  the  unequal  development  of  the  left  side 
of  the  spindle-shaped  dilatation  the  fundus  and  greater  curvature  of 
the  stomach  are  formed. 

Below  the  stomach  the  intestinal  tube  increases  rapidly  in  length. 
At  first  it  forms  a  loop,  attached  by  the  mesentery  to  the  spinal  col- 
umn, and  projecting  by  its  convex  surface  into  the  umbilical  vesicle. 
Afterward  it  is  thrown  by  its  rapid  growth  into  numerous  folds  and 
convolutions.  Finally,  the  distinctions  between  duodenum,  ilium,  and 
jejunum  become  apparent.  Previous  to  the  closure  of  the  abdominal 
walls  a  portion  of  the  intestine  protrudes  at  the  umbilicus.  A  persist- 
ence of  this  condition  up  to  the  time  of  birth  produces  congenital 
hernia. 

The  liver  begins  as  two  saccular  projections  from  the  duodenum. 
These  afterward  fuse  together  to  form  a  single  organ.  The  openings 
of  the  sacs  into  the  duodenum  constitute  the  bile-ducts,  which  are  at 
first  double,  but  subsequently  unite  to  form  a  single  canal.  The 
fibrous  coat  of  the  liver  and  the  vessels  are  derived  from  the  inner  layer 
of  the  mesoderm.  The  lobules  are  produced  from  branching  processes 
of  the  internal  or  glandular  layer  (entoderm).  The  growth  of  the  liver 
is  at  first  raj)id.  By  the  third  month  it  fills  nearly  the  entire  abdomen. 
Afterward,  by  the  growth  of  the  stomach  and  other  abdominal  viscera, 
the  liver  is  pushed  over  to  the  right  side.  Although  its  subsequent 
Igrowth  is  less  out  of  proportion  to  the  entire  body,  it  is  even  at  the  end 
pf  pregnancy  relatively  much  larger  than  in  the  adult, 
\  5 


66 


PHYSIOLOGY  OF  THE  OVUM. 


Fig.  58. — Heart  of  embryo  cMck  in  the  ear- 
liest stages  of  formation  (Eemak).  A, 
anterior  half  of  embryo  after  twenty- 
eight  to  thirty  hours  of  incubation  ;  B, 
after  about  thirty-six  hours  of  incuba- 
tion. 1,  1,  veins;  2,  auricle;  3,  ven- 
tricle ;  4,  aortic  bulb. 


In  like  manner  the  pancreas  is  developed  from  a  blind  process 
springing  from  the  left  side  of  the  duodenum.    The  pancreatic  duct 

is  at  first  single,  though  afterward 
it  often  becomes  double. 

The  terminal  portion  of  the  in- 
testine is  at  the  outset  straight. 
With  its  subsequent  growth,  how- 
ever, it  is  thrown  into  folds  and 
separates  into  a  longer  portion,  the 
colon;  and  a  shorter  portion,  the 
rectum. 

The  bladder  is  formed  from  the 
portion  of  the  allantois  which  is 
closed  in  by  the  abdominal  plates. 
The  allantois,  it  will  be  remem- 
bered, begins,  like  the  lungs  and 
the  liver,  as  a  blind  process  spring- 
ing from  the  intestinal  wall,  but  is 
situated  at  the  posterior  extremity 
of  the  tube.  At  the  outset,  there- 
fore, both  intestine  and  bladder 
open  into  a  common  cloaca.  Afterward,  however,  a  transverse  septum 
forms  between  the  genito-urinary  and  anal  openings. 

In  the  beginning  of  life  the  vascular  system  is  extremely  simple. 
The  heart  is  at  first  spindle-shaped,  and  composed  entirely  of  cells. 
It  then  assumes  an  S-shape,  and  becomes  hollow.  Fluid  accumulates 
in  the  cavity.  Single  cells  defcach  themselves  from  the  walls  and  float 
in  the  fluid.  These  are  the  earliest  blood-cells,  and  contain  nuclei. 
In  like  manner  the  vessels  are  at  first  solid  round  cell-cords,  which  be- 
come hollow,  fill  with  fluid,  and  furnish  nucleated  cells.  It  is  inter- 
esting, physiologically,  to  note  that  the  heart  pulsates  long  before  the 
muscular  fibers  appear,  and  when  it  is  composed  entirely  of  simple 
cells.* 

The  anterior  extremity  of  the  heart  is  connected  with  the  arterial 
system.  The  posterior  or  caudal  extremity  receives  the  venous  blood. 
The  heart  soon  becomes  bent  upon  itself,  and  projects  forward  on  the 
ventral  aspect  of  the  embryo,  and  to  the  right  side.  As  the  bending 
increases  the  arterial  and  venous  ends  approach  one  another.  Two 
slight  constrictions  divide  the  heart  into  three  compartments,  which 
open  into  one  a,nother.  The  first,  next  to  the  veins,  is  termed  the 
auricular  portion,  the  middle  one  is  the  ventricular,  and  the  last, 
which  is  the  primitive  arterial  trunk,  is  named  the  hulhus  arteriosus  " 
(Quain).    Fig.  58. 

The  bulbus  arteriosus  divides  into  two  branches,  which  convey  t 
*  A.  KoLLiKER,  "  Entwickelungs-Gcschichte,"  2te  Auflago,  p.  159. 


DEVELOPMENT  OF  THE  F(ETUS. 


67 


blood  from  the  heart  upward  to  the  first  (upper)  visceral  arch.  At 
this  point,  which  corresponds  to  the  future  base  of  the  brain,  they 
curve  backward  and  then  take  a  downward  course  in  front  of  the 
chorda  dorsalis.  These  two  branches  of  the  bulbus  arteriosus  are 
termed  the  superior  vertebral  arteries.  They  are  likewise  known  as 
the  aortic  arches.  Beneath  the  level  of  the  heart  they  unite  for  a  short 
distance  to  form  a  common  trunk,  which  in  turn  again  divides  into 
two  branches,  termed  the  inferior  vertebral  arteries.  These  latter  run 
parallel  to  one  another,  on  each  side  of  the  future  vertebral  column,  to 
the  caudal  extremity  of  the  embryo. 


Fig.  59. — Dia.fjram  of  heart  and  first  arterial  vessels  (Quain).  ^,  at  a  period  correspondinor 
to  the  thirty-sixth  or  thirty-eighth  hour  of  incubation ;  B  and  6',  at  the  forty-eighth 
hour  of  incubation.  1,1,  primitive  veins  •  2,  auricular  part  of  heart ;  3,  ventricular  part ; 
4,  aortic  bulb  ;  5,  5,  aortic  arches — in  (7,  tlaeir  coalescence  is  shown  at  a  '  in  below  the 
upper  5,  the  second  aortic  arch  is  formed,  and  farther  down  the  dotted  lines  indicate  the 
position  of  the  succeeding  arches  ;  5',  5',  continuation  of  main  vessels  (inferior  vertebral) ; 
6,  6,  omphalo-inesenteric  arteries. 

In  their  course  the  inferior  vertebral  arteries  give  off  branches  which 
are  at  first  limited  to  the  area  germinativa  by  a  circular  vein,  termed 
the  sinus  terminalis.  The  veins,  which  return  the  blood  to  the  embryo, 
occupy  a  lower  stratum  than  the  arteries,  and  empty  into  two  short 
trunks,  communicating  with  the  auricular  extremity  of  the  heart. 
Subsequently  the  sinus  terminalis  disappears,  and  two  arteries,  dis- 
tinguished by  their  superior  size,  pass  beyond  the  limit  of  the  area 
germinativa,  nov/  termed  the  area  vasculcsa,  to  extend  over  the  sur- 
face of  the  umbilical  vesicle.  These  vessels  are  known  as  the  "  07n- 
phalo-mesenteric^^  or  "vitelline^''  arteries.  At  first  four,  but  after- 
iWard  tAVo  veins,  bearing  the  same  name  as  the  corresponding  arteries, 
return  the  blood  to  the  embryo.  Finally,  the  two  omphalo-mesenteric 
ttrteries  and  veins  are  replaced  each  by  a  single  trunk,  so  that  the  en- 


G8  .  PHYSIOLOGY  OF  THE  OVUM. 

tire  vitelline  circulation  is  maintained  by  a  single  artery  and  a  single 
vein. 

According  to  this  arrangement,  the  simple  cylindrical  heart,  during 


Fig.  60. — Area  vasculosa  (Bischoff).    a,  a,  ^,  sinus  terminalis  ;  c,  omphalo-mesenteric  vein 
heart;  «,/,/,  posterior  vertebral  arteries. 

its  systole,  drives  the  blood  into  the  vertebral  arteries,  by  which  it  is 
distributed  to  the  different  regions  of  the  embryo,  and  especially  to 
the  walls  of  the  umbilical  vesicle.  There  it  becomes  charged  with  nu- 
tritive materials,  and  is  conveyed  back  to  the  heart  during  the  dias- 
tole by  the  omphalo-mesenteric  veins.  In  the  transition  from  the  vi- 
telline to  the  allantoic  or  placental  circulation,  corresponding  anatom- 
ical changes  take  place  in  the  entire  vascular  system.  Of  these  the 
more  noteworthy  are  as  follows  :  1.  The  single  ventricle  of  the  heart 
becomes  separated  into  two  compartments  by  the  gradual  growth  of  a 
partition  from  the  apex  to  the  auricular  portion.  At  the  end  of  the 
second  month  the  partition  is  complete,  and  the  heart  consists  of  two 
ventricles  and  a  single  auricle.  Next  a  partition  extending  from  the 
base  toward  the  ventricles  divides  the  single  auricle  into  a  right  and 
left  compartment.  This  partition,  unlike  the  ventricular  one,  is  in- 
complete posteriorly,  leaving  an  opening,  the  foramen  ovale,  which 
persists  throughout  the  entire  period  of  fetal  existence.  A  thin  cres- 
centic  fold,  termed  the  Eustachian  valve,  is  attached  to  the  anterior 
border  of  the  orifice  of  the  inferior  vena  cava.  The  Eustachian  valve 
divides  the  right  auricle  into  two  unequal  portions,  and  directs  the 


DEVELOPMENT  OF  THE  FCETUS. 


69 


blood  from  the  inferior  cava,  which  lies  behind  it,  through  the  fora- 
men ovale  into  the  left  auricle.  At  the  same  time  the  blood  from  the 
superior  cava,  passing  in  front  of  the  foramen  ovale  and  the  Eusta- 
chian valve,  pours  directly  into  the  right  ventricle.  A  thin  cres- 
centic  valvular  fold,  termed  the  valve  of  the  foramen  ovale,  grows 
from  the  posterior  surface  of  the  auricles  to  the  front.  It  is  situated 
a  little  to  the  left  of  the  foramen  ovale  and  projects  into  the  left  auri- 
cle. By  its  action  the  blood  is  allowed  to  pass  undisturbed  from 
right  to  left,  while  it  effectually  prevents  any  regurgitation  from  left 
to  right. 

2.  Meantime,  beneath  the  aortic  arches,  there  forms  a  series  of 
vascular  loops,  corresponding  in  number  and  situation  to  the  visceral 
arches  in  the  sides  of  the  neck  of  the  foetus  {vide  B,  Fig.  59).  They 
do  not  all,  however,  exist  contemporaneously.  A  number  of  them 
atrophy  and  disappear.  On  the  right 
side  the  third  and  fourth,  counting 
from  above  downward,  and  on  the  left 
side  the  third,  fourth,  and  fifth,  alone 
persist,  reserved  for  a  special  destiny. 
Soon  after  the  formation  of  the  sep- 
tum in  the  ventricular  portion  of  the 
heart,  the  bulbus  arteriosus  divides 
into  two  distinct  vessels,  of  which  one 
(B)  communicates  with  the  right,  and 
the  other  (A)  with  the  left  ventricle. 
The  left  division  (A)  communicates 
with  the  second  of  the  series  of  loops 
(counting  from  below)  formed  be- 
tween the  ascending  and  descending 
portions  of  the  aortic  arches.  The 
loop  on  the  right  side  (4)  becomes 
the  subclavian  artery  ;  that  on  the 
left  enlarges  and  forms  the  arch  of 
the  aorta.  The  right  division  of  the 
bulbus  arteriosus  (B)  opens  into  the 
first  vascular  loop  on  the  left  side. 
This  loop  gives  off  branches  (/?)  to  the 
lungs  and  becomes  the  pulmonary  ar- 
tery. That  portion  of  the  loop  situ- 
ated beyond  the  pulmonary  branches  continues 
open  communication  with  the  aorta,  and  is  termed  the 
riosus  (cl).  The  lower  portion  of  the  vertebral  artery 
side  becomes  the  permanent  aorta,  while  that  upon  the  right  side 
atrophies  and  disappears.  The  ascending  branches  of  the  primitive 
aortic  arches  furnish  the  common  and  external  carotids  {c  e).    The  in- 


FlG, 


61. — Diagram  of  the  vascular  arches, 
with  transformations  giving  rise  to 
the  permanent  arterial  vessels  (Kiith- 
ke).  The  aortic  bulb  is  divided  into 
A,  the  ascending  part  of  the  aortic 
arch ;  and  P,  the  pulmonary  part. 
The  vascular  arches  arc  numbered  1, 
2,  3,  4,  5,  from  below  upward,  p, 
pulmonary  branches  ;  ductus  arte- 
riosus ;  e  <?,  external  carotids  ;  e 
and  c  i\  internal  carotids. 


during 


fetal  life  in 
ductus  arte- 
on  the  left 


70 


PHYSIOLOGY  OF  THE  OVUM. 


ternal  carotids  (ci)  are  formed  from  the  third  vascular  loops  and  a 
portion  of  the  vertebral  arteries. 

The  umbilical  arteries  at  first  take  their  origin  from  the  inferior 
vertebral  arteries,  and  afterward  from  the  hypogastric  or  internal  iliac 
arteries. 

The  umbilical  vein  enters  the  abdomen  at  the  navel,  and  thence 
passes  to  the  lower  surface  of  the  liver ;  it  gives  off  a  number  of 
branches  to  the  left  lobe,  the  lobus  quadratus,  and  the  lobus  Spigelii. 
At  the  transverse  fissure  it  divides  into  two  branches,  the  larger  of 
which  empties  directly  into  the  portal  vein,  and  supplies  the  right  lobe 
with  umbilical  blood  ;  the  other  passes  to -the  inferior  vena  cava,  and 
is  termed  the  ductus  venosus.  Thus  the  greater  portion  of  the  regen- 
erated blood,  brought  by  the  umbilical  vein  from  the  placenta,  first 
passes  through  the  liver  before  entering  the  general  circulation  of  the 
foetus,  while  the  lesser  amount  empties  at  once  into  the  inferior  vena 
cava.  As,  however,  with  the  advance  of  gestation,  the  relative  dispro- 
portion between  the  hepatic  trunks  and  the  ductus  venosus  is  in- 
creased, toward  the  end  nearly  all  the  blood  from  the  placenta  has  to 
make  the  circuit  of  the  liver. 

Thus  the  inferior  vena  cava  carries  to  the  right  auricle,  in  part, 
blood  from  the  lower  extremities  charged  with  effete  matters,  and, 
in  part,  placental  blood,  either  received  direct  from  the  umbilical  vein 
through  the  ductus  venosus,  or  after  having  previously  traversed  the 
liver. 

In  the  foetus  the  currents  of  blood  through  the  heart  are  especially 
adapted  to  the  un expanded  condition  of  the  pulmonary  organs.  Previ- 
ous to  the  first  respiratory  act  at  birth,  the  lung  is  small,  and,  were 
the  entire  contents  of  the  right  side  of  the  heart,  as  in  the  adult,  at 
once  discharged  into  the  pulmonary  vessels,  intense  engorgement  with 
rupture  of  the  capillaries  would  ensue.  This  danger  is,  however, 
averted  by  the  anatomical  peculiarities  already  stated.  Thus,  in  the 
early  months  the  blood  from  the  inferior  cava,  in  place  of  empty- 
ing from  the  right  auricle  into  the  right  ventricle,  passes  directly 
across  the  right  auricle,  guided  by  the  Eustachian  valve,  through  the 
foramen  ovale  to  the  left  auricle,  and  thence  to  the  left  ventricle.  As 
the  heart  contracts  it  enters  the  aorta,  and  is  distributed  by  the  large 
vessels  which  spring  from  the  latter  to  the  head  and  upper  extremi- 
ties. The  blood  returned  from  the  upper  portion  of  the  body  by  the 
superior  vena  cava  enters  the  right  auricle,  where  it  passes  in  front  of 
the  Eustachian  valve  into  the  right  ventricle.  A  commingling  of  the 
currents  from  the  superior  and  inferior  venae  cavse  in  the  right  auricle 
is  almost  completely  prevented  in  the  earlier  months  by  the  Eustachian 
valve.  With  the  advance  of  gestation,  however,  a  gradual  disappear- 
ance of  the  Eustachian  valve  takes  place,  so  that  a  part  of  the  blood 
from  the  inferior  cava  enters  with  that  of  the  superior  cava  into  the 


DEVELOPMENT  OF  THE  FCETUS. 


71 


right  ventricle.  The  contraction  of  the  right  ventricle  forces  the  blood 
into  the  pulmonary  artery,  which  distributes  an  insignificant  quantity 
to  the  lungs,  while  the  main  current  passes  through  the  ductus  arteri- 


Internal  Iliac  Arteries. 
Fig.  62. — Diagram  of  the  fetal  circulation.  (Flint.) 


72 


PHYSIOLOGY  OF  THE  OVUM. 


osus  into  the  aorta,  by  which  it  is  distributed  to  the  lower  portion  of 
the  body. 

Thus  it  will  be  noted  that  at  all  times  provision  is  made  for  sup- 
plying the  head  and  upper  parts  of  the  body  with  regenerated  placen- 
tal blood.  On  the  other  hand,  the  lower  extremities  are  for  a  time 
almost  entirely  supplied  with  blood  which  has  already  fed  the  tissues 
and  received  the  waste  of  the  upper  portion  of  the  body.  As  preg- 
nancy, however,  advances,  with  the  disappearance  of  the  Eustachian 
valve,  a  small  measure  of  placental  blood  is  likewise  distributed  to  the 
lower  portion  of  the  body.  This  is  in  unison  with  the  well-known 
fact  that  the  relative  development  of  the  lower  extremities  increases  as 
the  end  of  gestation  is  approached. 

With  the  cessation  of  the  placental  circulation  at  birth,  the  um- 
bilical vessels  close,  with  the  exception  of  the  umbilical  arteries,  wiiich 
remain  pervious  at  their  lower  portion  and  constitute  the  vesical  arte- 
ries. After  the  establishment  of  respiration,  the  blood  from  the  right 
side  of  the  heart  makes  the  circuit  of  the  lungs  and  returns  to  the  left 
side  by  the  pulmonary  veins.  The  ductus  arteriosus  then  contracts 
and  disappears.  As  the  left  auricle  fills  with  blood,  the  joressure  closes 
the  valve  of  the  foramen  ovale.  Occasionally,  however,  the  foramen 
ovale  remains  open  after  birth,  and  allows  a  portion  of  the  venous 
blood  to  pass  from  the  right  to  the  left  auricle.  We  have  then  one 
form  of  the  condition  known  as  cyanosis  neonatorum,  an  affection 
characterized  by  intermittent  attacks  of  dyspnoea,  blueness  of  the  sur- 
face of  the  body,  and  depression  of  the  temperature. 

Development  of  the  Fcetus  in"  the  Successive  Moi^ths  of 

Pregnan^cy. 

It  is  customary  to  reckon  the  duratio7i  of  pregnancy  at  two  hun- 
dred and  eighty  days,  and  to  divide  that  space  into  ten  months  of 
twenty-eight  days  each.  As  it  is  often  a  matter  of  importance  that  an 
accoucheur  should  be  able  to  judge  the  age  of  a  prematurely  expelled 
embryo  or  foetus,  the  following  particulars  concerning  the  changes  in 
each  month  are  furnished  as  a  guide  to  the  formation  of  an  opinion. 
In  the  writer's  experience  all  rules  regarding  the  age  of  the  ovum 
possess,  however,  nothing  more  than  an  approximative  value,  owing 
to  the  very  great  normal  variations  in  the  rapidity  of  development  in 
different  individual  cases. 

First  Month. — At  the  end  of  tlie  second  week,  the  embryo  is  rep- 
resented by  the  embryonic  spot,  which  has  assumed  a  biscuit-shape. 
The  dorsal  plates  are  developed.  The  entire  ovum  measures  one  fourth 
of  an  inch,  and  the  embryo  one  twelfth  of  an  inch.  A  week  later  the 
embryo  has  doubled  in  length,  and  presents  as  special  features  a  curv- 
ing of  the  back,  an  enlargement  of  tlie  cephalic  extremity,  with  rudi- 
ments of  the  three  higher  organs  of  special  sense,  and  the  appearance 


DEVELOPMENT  OF  THE  FGETUS. 


73 


of  the  visceral  arches.  The  amnion  is  fully  developed.  The  embryo  is 
nourished  by  the  umbilical  vesicle^  The  allantois  carries  the  vessels 
from  the  embryo  to  the  periphery  of  the  ovum,  but  the  vessels  do  not 
penetrate  the  villi.  An  ovum  described  by  Waldeyer,  exactly  four  weeks 
old,  was  of  about  the  size  of  a  pigeon-egg,  and  three  fourths  of  an  inch 
long  by  two  thirds  of  an  inch  broad.  It  weighed  upward  of  two  scru- 
ples. The  embryo  measured  nearly  one  third  of  an  inch  in  length,  or 
four  fifths  of  an  inch  in  length  following  the  dorsal  curvature  from 
the  top  of  the  cephalic  extremity  lu  the  end  of  the  coccyx.  The  head 
of  the  embryo  presented  the  primitive  cerebral  vesicles.  The  eyes  were 
in  the  sides  of  the  head,  and  the  ears  posterior  to  the  eyes.  Beneath, 
the  visceral  arches  were  well  marked.  Four  bud-like  processes  indi- 
cated the  beginnings  of  the  anterior  and  posterior  extremities.  The 
intestine,  with  anal  and  oral  openings,  was  formed.  The  cord  was 
short  and  thick,  with  a  single  vein  and  two  arteries.  The  amnion  was 
only  moderately  distended,  and  space  still  existed  between  the  amnion 
and  chorion.    The  umbilical  vesicle  was  tolerably  large. 

Second  Month. — An  embryo  described  by  Waldeyer  from  the  sixth 
to  the  seventh  week  measured  about  one  inch  in  length,  following  the 
dorsal  curve.  Another  in  the  eighth  week  described  by  Ecker  meas- 
ured two  thirds  of  an  inch  in  a  direct  line  from  the  head  to  the  caudal 
curve.*  The  ovum  itself  was  of  about  the  size  of  a  hen's-egg.  The 
amnion  at  the  end  of  the  second  month  is  distended  with  fluid  and  in 
contact  with  the  chorion. f  The  villi  become  abundant  near  the  im- 
plantation of  the  umbilical  cord.  The  umbilical  vesicle  is  greatly 
reduced  in  size,  and  hangs  from  the  embryo  by  a  slender  pedicle. 
The  umbilical  cord  is  increased  in  length,  but  its  vessels  do  not  yet 
assume  a  spiral  direction.  The  umbilical  ring  is  small,  though  still 
containing  loops  of  intestine.  Ossification  begins  in  the  lower  jaw 
and  clavicle.  The  three  divisions  of  the  extremities  are  clearly  indi- 
cated. 

Third  Month. — Toward  the  end  of  the  third  month  the  ovum  meas- 
ures nearly  four  inches  in  length.  The  embryo  is  between  three  and 
three  and  a  half  inches  long,  and  weighs  about  an  ounce.  The  chorion 
has  lost  in  great  measure  its  villosities.  The  |)lacenta  is  formed, 
though  of  small  size.  The  cord  lengthens,  and  forms  spiral  turns. 
The  neck  now  separates  the  head  from  the  trunk.  The  development 
of  the  ribs  distinguishes  the  thorax  from  the  abdomen.  The  mouth 
is  closed  by  the  lips,  and  the  nasal  separated  from  the  oral  cavity  by 
the  palate.  Points  of  ossification  appear  in  most  of  the  bones.  Thin, 
membrane-like  nails  appear  upon  the  fingers  and  toes.  The  scrotum 
and  labia  majora  begin  to  form  from  cutaneous  folds.  The  penis  and 
clitoris  do  not  difi'er  from  one  another  in  length. 

*  SriEGELBK RO,  "  Lclirbuch  der  Gcbui-tshiilfe,"  p.  84. 
f  Loc.  cit.^  p.  81. 


74 


PHYSIOLOGY  OF  TEE  OVUM. 


Fourth  Month. — Toward  the  end  of  the  fourth  month  there  is  an 
increase  of  size  and  thickness  in  the  placenta.  The  cord  is  increased 
to  two  or  three  times  the  length  of  the  foetus,  and  has  become  thicker 
from  the  formation  of  the  gelatine  of  Wharton.  The  foetus  measures 
four  to  six  inches  in  length.  The  weight  is  estimated  all  the  way  be- 
tween two  and  four  ounces.  The  head  of  the  foetus  is  one  fourth  the 
length  of  the  entire  body.  The  bones  of  the  skull  are  partly  ossified. 
The  sutures  and  fontanelles  are  widely  separated.  The  mouth,  eyes, 
ears,  and  nose  assume  their  proper  shape.  The  sex  is  distinguishable, 
the  skin  firmer,  and  hair  begins  to  form  upon  the  scalp.  The  foetus 
makes  slight  movements  with  its  limbs. 

Fifth  Month. — The  foetus  measures  from  seven  to  ten  inches  in 
length,  and  weighs  nearly  ten  ounces.  The  head  is  still  relatively 
large.  The  face,  however,  is  wrinkled,  and  wears  a  senile  aspect. 
Fine  hair  (lanugo)  appears  over  the  whole  surface  of  the  body.  The 
fetal  movements  are  now  distinctly  felt  by  the  mother. 

Sixth  Month. — Near  the  end  of  the  sixth  month  the  foetus  is  eleven 
to  thirteen  inches  long  and  weighs  about  twenty-three  ounces.  The 
deposition  of  fat  in  the  subcutaneous  cellular  tissue  begins.  The  eye- 
lids separate.  A  foetus  born  at  this  time  breathes  feebly,  but  in  the 
course  of  a  few  hours  dies. 

Seventh  Month. — The  foetus  measures  fourteen  to  fifteen  inches, 
and  weighs  in  the  neighborhood  of  thirty-nine  ounces.  The  skin  is 
still  wrinkled,  of  a  red  color,  and  covered  with  vernix  caseosa.  Chil- 
dren born  between  the  twenty-fourth  and  the  twenty-eighth  week 
move  their  limbs  and  cry  feebly  at  birth,  bat  in  spite  of  every  care 
they  die  in  the  course  of  a  few  hours  or  days. 

Note. — Ahlfeld  has  recently  suggested  the  inquiry  as  to  whether  the  assumption,  that 
children  born  before  the  completion  of  the  twenty-eighth  week  necessarily  perish,  is  not 
too  arbitrary.  Many  practitioners  have  observed  instances  of  the  survival  of  a  premature 
child  which,  both  from  the  data  obtained  from  the  parents  and  from  all  the  indications 
presented  by  the  child,  they,  at  the  time  of  birth,  had  placed  within  the  limit  regarded  as 
hopeless.  Ahlfeld  has  culled  a  number  of  such  cases  from  the  published  literature  of  the 
subject.  Granting  the  many  sources  of  error  which  would  lead  us  to  accept  such  cases 
with  caution,  it  none  the  less  seems  incumbent  upon  us  to  regard  Ahlfeld's  advice,  and 
look  upon  every  child  which  respires  at  birth  as  one  whose  life  may  possibly  be  preserved 
by  suitable  care.  It  may  be  that  the  skepticism  of  medical  men  may  be  in  part  the  cause 
of  the  unfavorable  results.* 

Eighth  Month. — The  foetus  measures  sixteen  to  seventeen  inches, 
and  weighs  upon  tlie  average  about  fifty-two  ounces.  The  papillary 
membrane  disappears  ;  the  hair  of  the  head  increases  in  thickness  ;  the 
lanugo  begins  to  disappear  from  the  face  ;  the  nails  are  harder,  but 
do  not  yet  reach  the  tii:»s  of  the  fingers.  Usually,  in  boys,  a  testicle 
may  be  felt  in  the  scrotum  ;  the  naA^l  is  situated  nearly  in  the  center 

*  Ahlfeld,  "  Ueber  unzeitig  und  schr  friihzeitig  geborene  Friichte  die  am  Leben 
blieben,"  "Arch.  f.  Gynaek.,"  Bd.  viii,  p.  194. 


DEVELOPMENT  OF  THE  FCETUS. 


75 


of  the  child's  body.  With  care,  the  hfe  of  a  child  born  within  tliis 
period  may  be  preserved. 

Ninth  Month. — The  length  is  between  sixteen  and  a  half  and  seven- 
teen and  a  half  inches  ;  the  weight  is  about  sixty-four  ounces  ;  the 
body  becomes  rounded  and  the  face  more  comely,  losing  its  wrinkled, 
antiquated  aspect ;  the  bones  of  the  head  bend  easily,  and  the  lanugo 
begins  to  disappear  from  the  body.  Children  at  this  period  are  less 
energetic  than  at  full  term,  deep  a  great  part  of  the  time,  and  are 
prone  to  die  with  lack  of  careful  attention. 

Tenth  Month. — In  the  first  two  weeks  the  foetus  measures  eigh- 
teen to  nineteen  inches,  and  weighs  about  seventy-seven  ounces.* 

For  convenience  of  reckoning  from  memory  it  is  sufficiently  accu- 
rate to  assume  the  length  of  the  child  in  the  third  and  fourth  month 
at  respectively  three  and  four  inches.  In  the  fifth,  sixth,  seventh, 
and  eighth  months  close  approximations  to  the  average  length  may  be 
obtained  by  doubling  the  number  of  months.  In  the  ninth  and  tenth 
months  the  length  may  be  placed  respectively  at  seventeen  and 
eighteen  inches. 

The  Foetus  at  Term. — In  the  child  at  birth  the  body  is  well  rounded, 
and  the  skin  has  lost  its  deep-red  coloring  ;  the  fine  down  (lanugo) 
has,  for  the  most  part,  disappeared  ;  the  nails  project  beyond  the  fin- 
ger-tips ;  in  the  male  the  scrotum  contains  both  testicles,  and  in  the 
female  the  labia  majora  are  in  contact.  In  the  fifth  month  the  sur- 
face of  the  fetal  body  is  covered  by  the  vernix  caseosa,  a  whitish  sub- 
stance composed  of  a  commingling  of  surface  epithelium,  down,  and 
the  products  of  the  sebaceous  glands.  This  coating  probably  protects 
the  skin  during  intra-uterine  life  from  the  penetration  of  the  amniotic 
fluid.  The  amount  of  this  substance  upon  the  body  is  very  variable 
at  birth,  when  it  is  chiefly  found  upon  the  back  and  flexor  surfaces 
of  the  extremities. 

Children  at  term  cry  lustily  soon  after  birth,  move  their  limbs 
freely,  and  nurse  when  put  to  the  breast.  In  the  first  few  hours  they 
pass  urine  and  the  so-called  meco9iium,  a  mixture  of  intestinal  mucus 
with  epithelium,  epidermis  cells,  lanugo,  and  bile,  which  gives  to  it  a 
black  or  brownish-green  color. f 

The  average  length  at  birth  is  from  twenty  to  twenty-one  inches. 
The  average  weight  seems  to  be,  in  some  degree,  dependent  upon  race 

*  The  weights  and  measures  are  taken  from  Hecker's  averages,  based  on  486  observa- 
tions.   {Vide  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxvii,  1SG6.) 

Observations  of  Fesser  showed  similar  results.  ("  Lelivbuch  der  Geburtshiilfe,"  von 
Otto  Spiegelberg,  1877,  p.  86.) 

Ahlfeld  obtained  considerably  larger  averages  from  250  observations  in  which  the 
date  of  conception  could  be  determined.  ("  Bestimmungcn  der  Grosse  und  des  Alters  der 
Frucht  vor  der  Geburt,"  "Arch.  f.  Gynaek.,"  ii,  1871,  p.  361.) 

f  ZwEiFEL,  "  Untersuchungen  iiber  das  Meconium,"  "  Arch.  f.  jGynaek  ,"  Bd,  vii,  1875^ 
p.  474. 


76 


PHYSIOLOGY  OF  THE  OVUM. 


peculiarities.  Scanzoni*  found,  in  nearly  9,000  births,  an  average 
for  both  sexes  of  nearly  seven  pounds.  Ingerslev,f  in  Coj)enhagen, 
from  statistics  based  upon  3,450  births,  arrived  at  nearly  the  same 
results.  Hecker,|  in  Munich,  out  of  something  over  1,000  births, 
obtained  six  and  four-fifths  pounds  as  the  average  ;  while  Fesser,*  in 
Breslau,  found  it  only  six  and  a  half  pounds.  Bailly  ||  likewise  reports 
the  average  weight  as  something  less  than  seven  pounds.  The  weights 
of  200  infants  born  in  the  Bellevue  Hospital  gave  to  tlie  writer  an  aver- 
age of  seven  and  two  thirds  pounds  for  the  two  sexes.  The  boys 
averaged  seven  and  nine  tenths  pounds,  and  the  girls  seven  and  one 
third  pounds.  Three  fourths  of  the  mothers  were  of  Irish  birth,  one 
fifth  were  born  in  America,  while  the  remaining  fraction  was  divided 
between  English,  Scotch,  and  Germans.  The  largest  child  weighed 
eleven  pounds.  Ingerslev's  largest  child  weighed  ten  and  three  eighths 
pounds  ;  Hecker  found  two  weighing  between  ten  and  eleven  pounds  ; 
La  Chapelle,  out  of  7,000  cases,  found  thirteen  infants  weighing  ten 
pounds,  but  none  exceeded  that  limit.  Credible  histories  ^  of  children 
weighing  from  twelve  to  sixteen  pounds  are  extant ;  such  children 
have  generally  been  still-born.  Waller,  however,  reports  a  case  of 
a  living  infant  delivered  by  him  with  forceps,  which  weighed  fifteen 
pounds  fifteen  ounces.^  The  size  of  the  child  is  influenced  in  especial 
by — 1.  The  sex.  Boys  average  a  greater  weight  than  girls.  2.  The 
number  of  pregnancies.  The  children  of  primiparae  average  less  than 
those  of  multiparas.  The  increase  in  weight  of  children  in  each  succes- 
sive pregnancy  is  progressive,  though  this  law  is  liable  to  interruption 
where  pregnancies  follow  one  another  too  rapidly,  or  in  cases  in  which 
there  is  a  change  of  sex.  In  the  latter  instance  the  variation  is  to  the 
disadvantage  of  the  female  born  in  succession  to  a  male.J  3.  The  age 
of  the  mother.  Duncan  found  the  greatest  weight  in  children  born 
of  mothers  between  the  twenty-fifth  and  twenty-ninth  years  ;  J  Wcr- 
nich,  between  the  thirtieth  and  thirty-fourth  years.  J  4.  The  constitu- 
tion and  health  of  the  parents.  By  some,  too,  the  size  of  the  father 
is  supposed  to  exercise  an  influence  upon  that  of  the  child. 

The  Fetal  Cranium. — Except  in  children  of  exaggerated  size,  the 

*  ScANZONi,  "Lcbrbuch  der  Geburtshiilie,"  p.  96. 

f  Ingerslkv's  "On  the  Weight  of  New-born  Children,"  "  Obstct.  Jour.,"  iii,  18'76, 
p.  705. 

X  "Klinik  der  Gebiirtskunde,"  ii,  1864. 

*  Spiegelrerg,  "  Lehrbiich  der  Geburtshiilfc,"  p.  86. 

II  IJailly,  "  Nouveau  Dictionnaire,"  t.  xv,  art.  "  Foetus,"  p.  5. 

^  Naegele's  "  Lchrbucli  der  Geburtrihulfe,"  bcarbcitct  von  Grouser,  8te  Auflage,  p.  624. 
()  Walleu,  London  "  Obstet.  Trans  ,"  vol.  i,  p.  309. 

:|;  Wernioh,  "Uebcr  die  Zuniihmc  der  weiblichcn  Zcugungsfahigkcit,"  "Bcitr.  zur 
Gcburtsh.,"  Bd.  1,  p.  3. 

^  Duncan,  "Fecundity,  Fertility,  and  Sterility,"  p.  53. 
I  Zoc.  cit.,  p.  10. 


DEVELOPMENT  OF  THE  F(ETUS. 


77 


head  is  the  most  yoluminous  and  unyielding  part  whicli  has  to  traverse 
the  parturient  canal.*  The  diameters  of  the  head  and  the  physical 
characters  of  its  bones  are  chiefly  of  importance  in  connection  with  the 
mechanism  of  labor.  Their  consideration  may,  therefore,  be  conven- 
iently postponed  to  the  study  of  that  subject.  A  knowledge,  how- 
ever, of  the  general  structure  of  the  skull  is  essential  to  the  diagnosis 
of  pregnancy. 

The  face  is  very  small  in  proportion  to  the  cranium.  The  latter 
consists  of  the  two  frontal  bones,  the  two  parietal  bones,  the  occipital 
bone,  the  temporal  bones,  and  the  alae  of  the  sphenoid  bone.  At 
birth  these  various  bones  are  not,  as  in  the  adult,  directly  articulated 
together,  but  are  united  by  means  of  fibrous  bands,  termed  sutures, 


Fig.  63. — Fetal  head,  side-view.  Fig.  64. — Fetal  head,  viewed  from 

(Hodge.)  above.  (Hodge.) 

in  which  ossification  subsequently  takes  place.  It  is  important  to  be- 
come familiar  with  the  following  sutures  :  1.  The  frontal  suture, 
between  the  frontal  bones.  2.  Tlie  sagittal  suture,  between  the  two 
parietal  bones.  3.  The  coronal  suture,  between  the  frontal  and  parie- 
tal bones.  4.  The  lanibda  suture,  between  the  occipital  and  two  parie- 
tal bones. 

When  three  or  more  bones  meet  together,  the  rounded  angles  of 
the  bones  offer  at  the  point  of  concurrence  a  deficiency  of  osseous  sub- 
stance, which  is  closed  by  fibrous  membrane  similar  to  that  which 
forms  the  sutures.  These  membranous  interspaces  are  termed  fonta- 
nelles.  Two  of  these,  the  large  anterior  and  the  small  posterior  fonta- 
nelle,  are  of  immediate  obstetrical  interest,  as  they,  with  the  sutures, 
furnish  the  guiding  points  which  enable  the  examining  finger  to 
determine,  in  advanced  pregnancy,  the  position  of  the  child's  head. 

The  large  fontanelle,  or  bregmatic  space  (bregma,  the  sinciput), 
occupies  the  gap  between  the  parietal  and  frontal  bones.  It  possesses 
a  lozenge-shape.  Its  anterior  angle  is  continuous  with  the  frontal 
suture ;  its  posterior  angle  with  the  sagittal  suture  ;  and  its  lateral 
angles  with  the  two  halves  which  compose  the  coronal  suture.  Its 
anterior  angle  is  much  longer  than  the  posterior  angle. 

The  small  fontanelle  is  situated  at  the  junction  of  the  occipital 
with  the  parietal  bones.    It  is  of  a  triangular  shape,  and,  as  its  name 

*  In  bulky  children,  the  shoulders  sometimes  offer  the  greatest  difficulties  in  delivery. 


78 


PHYSIOLOGY  OF  THE  OVUM. 


indicates,  of  small  size.  As  a  rule,  it  no  longer  exists  at  birth, 
owing  to  the  complete  ossification  of  the  angles  which  form  it. 

The  anterior  fontanelle  may  be  recognized  by  the  finger,  during 
labor,  by  its  large  size,  its  lozenge  shape,  and  by  its  four  converging 
sutures  which  cross  one  another  at  right  angles.  The  posterior  fon- 
tanelle, on  the  contrary,  is  small  and  triangular ;  the  sagittal  suture 
forms,  with  the  lambda  suture,  an  obtuse  angle  on  either  side,  and 
terminates  at  the  occipital  bone.  During  the  descent  of  the  child's 
head  into  the  pelvis,  the  occipital  bone  is  frequently  depressed  beneath 
the  parietal  bones,  which  thus  form  a  relief,  along  which  the  finger 
readily  passes  to  the  site  of  the  small  fontanelle,  even  when  the  latter 
no  longer  exists  as  an  open  gap  or  space. 

The  Attitude,  Presentation,  and  Position  of  the  Fcetus. 

The  attitude  of  the  foetus  in  utero  is  as  follows  :  The  spinal  column 
is  bent  forward,  the  chin  is  inclined  toward  the  chest,  the  arms  are 

bent  at  the  elbow,  and  the  forearms 
are  crossed  upon  the  breast,  the  thighs 
are  flexed  upon  the  abdomen,  and  the 
feet  extended  so  as  to  come  in  contact 
with  the  legs,  which,  like  the  fore- 
arms, are  often  crossed.  By  this  ar- 
rangement the  foetus  assumes  the 
smallest  bulk,  and  presents  an  ovoid 
form,  of  which  the  head  furnishes  the 
smaller  end. 

By  presentaJion  we  understand 
that  portion  of  the  foetus  which  oc- 
cupies the  lower  segment  of  the  ute- 
rus. By  the  determination  of  the 
presentation,  we  are  enabled  to  decide 
upon  the  relation  of  the  axis  of  the 
child  to  the  long  diameter  of  the  ute- 
rus. When  these  two  coincide,  either 
of  the  two  extremities  of  the  child, 
viz.,  the  head  or  the  breech,  becomes 
the  presenting  part.  When  the  long 
diameter  of  the  child  corresponds  to 
the  oblique  or  transverse  diameter  of 
the  uterus,  the  shoulder  becomes  the 
presenting  part. 

Though  head-presentations  form, 
during  labor,  by  far  the  large  majority  of  all  cases  (ninety-six  per 
cent.),  changes  of  position  are  very  common  during  pregnancy.  The 
frequency  of  these  changes  is  in  inverse  ratio  to  the  advance  of  preg- 


FiG.  65. — Attitude  of  foetus   in  utero. 
(Tumier  ct  Chantreuil.) 


DEVELOPMENT  OF  THE  FffiTUS. 


79 


nancy,  occurring  with  diminished  frequency  in  the  later  months.  In 
multiparae  they  take  place  oftener  than  in  primiparae.  In  multiparas 
they  occur  not  rarely  shortly  before  birth,  while  it  is  exceptional  in 
primiparae  for  tliem  to  take  place  in  the  last  three  weeks  of  pregnancy. 
Great  ingenuity  has  been  exercised  to  account  for  the  preponderating 
frequency,  at  the  time  of  labor,  of  head-presentations.  Hippocrates 
taught  that,  during  the  early  months  of  pregnancy,  the  foetus  occu- 
pied a  sitting  posture,  with  the  head  uppermost.  In  the  seventh 
month,  however,  it  made  a  complete  turn  or  somersault  preparatory  to 
its  exit  from  the  womb,  an  act  accomplished  by  the  voluntary  efforts 
of  the  child.  Aristotle  referred  the  head-presentations  to  the  laws  of 
gravity,  a  theory  which  has  always  had  many  adherents  and  is  still 
actively  defended  at  the  present  day.* 

Dubois  f  made  a  serious  breach  in  this  doctrine  by  showing  that  if 
he  allowed  a  dead  foetus,  of  any  period  between  the  fourth  and  ninth 
monthj  to  sink  in  a  vessel  filled  with  water,  it  was  not  the  head,  but 
the  back  or  right  shoulder  which  first  reached  the  bottom.  Dubois 
thereupon  denied  the  influence  of  gravity,  and  referred  the  head-pres- 
entatioDS  to  instinctive  or  voluntary  movements  on  the  part  of  the 
foetus,  designed  to  bring  it  into  a  position  best  adapted  for  intra- 
uterine domicile,  or  for  parturition.  He  likewise  argued  against  the 
gravitation  theory,  that  in  premature  births,  and  in  children  who  die 
in  utero,  pelvic  and  transverse  presentations  are  very  common,  a  fact 
that'would  be  inexplicable  were  gravity  the  sole  or  chief  force  in  opera- 
tion. Simpson  I  agreed  with  Dubois  in  ascribing  the  cephalic  pres- 
entations to  fetal  movements,  but,  in  place  of  the  instinctive  or 
voluntary  movements  of  Dubois,  substituted,  in  an  argument  of  ex- 
traordinary ingenuity,  a  theory  of  reflex  action.  Thus,  the  frequency 
of  malpositions  in  the  first  six  months  of  pregnancy  was  explained  by 
the  spheroidal  shape  of  the  uterine  cavity,  which  allov/s  of  unrestrained 
fetal  movements.  In  the  latter  months,  however,  as  the  uterus  as- 
sumed a  more  ovoid  shape,  it  was  only  when  the  child  was  situated  in 
the  uterus  with  the  head  lowest  that  a  physical  adaptation  between 
foetus  and  uterus  existed.  In  case,  from  any  cause,  therefore,  a  devia- 
tion from  this,  the  normal  position,  took  place,  the  pressure  upon 
the  cutaneous  surface  of  the  child,  by  the  uterine  wall,  would  give  rise 
to  excito-motory  movements  of  an  adaptive  kind,  calculated  to  restore 
the  disturbed  presentation.    Duncan  *  and  Veit  succeeded  in  partially 

*  Vide  historical  part  of  Cohnsteiu's  paper  entitled  "  Die  Aetiologie  der  normalen  Kin- 
derlage,"  "Monatssch.  f.  Geburtsk.,"  Bd.  xxxi,  p.  142. 

f  Dubois,  "  Memoire  sur  la  cause  dcs  presentations  de  la  tote,"  "  Mem.  de  I'Acad.  Roy. 
de  Med.,"  tome  ii,  1833,  p.  265. 

X  Simpson,  "  Attitude  and  Positions  of  the  Foetus  in  Utero,"  "  Obstetric  Works," 
edited  by  Priestley  ftnd  Storer,  vol.  ii,  p.  SI. 

*  Duncan,  "Researches  in  Obstetrics,"  p.  14.  Veit,  Scanzoni's  "Beitrage,"  Bd.  iv, 
p.  279. 


80 


PHYSIOLOGY  OF  THE  OVUM. 


rehabilitating  the  gravitation  theory  by  showing  that,  notwithstanding 
Dubois's  experiments,  the  center  of  gravity  lies  much  nearer  the  ce- 
phalic than  the  pelvic  extremity  of  the  child.  They  found  that  a 
fresh  foetus  immersed  in  a  saline  fluid  possessing  nearly  the  same  spe- 
cific gravity  as  the  foetus,  in  place  of  sinking  upon  its  back  or  side  to 
the  bottom  of  the  vessel,  assumed  an  oblique  direction  in  the  fluid 
with  the  right  shoulder  looking  downward.*  They,  therefore,  con- 
cluded that  the  foetus,  lying  upon  the  inclined  plane  furnished  by  the 
uterine  walls,  would  naturally  assume  a  similar  position,  were  no  other 
forces  operative  to  interfere.  Finally,  we  have  the  opinion  of  Crede,  of 
Kristeller,f  and  of  Braxton  Hicks,  |  that  the  contractions  of  the  preg- 
nant uterus  adapt  the  position  of  the  foetus  to  the  form  of  the  uterus. 

Now,  each  one  of  these  conflicting  ideas  undoubtedly  represents  a 
portion  of,  but  not  all,  the  truth.  It  is  certain  that  all  the  influences 
cited  do  exist,  and  it  only  remains  for  us  clinically  to  assign  to  each  its 
relative  value.  In  the  early  months  of  pregnancy,  the  spheroidal 
shape  of  the  uterine  cavity,  the  small  size  of  the  foetus  in  comparison 
with  that  of  the  uterus,  and  the  large  proportion  of  amniotic  fluid,  all 
allow  the  foetus  the  greatest  measure  of  mobility.  At  this  time  the 
position  of  the  child  must  be  influenced  by  the  active  movements, 
which  are  felt  by  the  mother  subjectively  often  as  early  as  the  four- 
teenth week.  As,  usually,  during  the  first  half  of  pregnancy  even, 
the  shoulder  and  head  are  turned  downward,  it  is  fair  to  ascribe  this 
position  to  the  laws  of  gravity.  The  frequency  of  malpresentations  in 
premature  labors  is  explained  in  part  by  the  tardy  dilatation  of  the 
cervix  and  the  mobility  of  the  foetus,  which  render  easy  the  displace- 
ment of  the  head  from  its  first  position,  under  the  influence  of  press- 
ure exerted  upon  the  axis  of  the  child's  body.  Malpresentations 
are  more  frequent  in  the  case  of  a  dead  foetus  than  in  the  living, 
but  Duncan  has  shown  that  in  the  dead  foetus,  owing  to  post-mortem 
changes,  the  center  of  gravity  often  shifts  toward  the  pelvic  ex- 
tremity. With  the  advance  of  pregnancy,  as  the  longitudinal  ex- 
ceeds the  lateral  growth  of  the  uterus,  the  child  adapts  itself  to  the 
long  axis  of  the  uterus  ;  and  the  further  pregnancy  advances  the  more 
complete  the  adaptation  becomes.  When  from  any  cause  or  condition 
the  correspondence  between  the  fetal  and  uterine  axis  is  disturbed, 
compression  of  a  portion  of  the  cutaneous  surface  of  the  foetus  results. 
Reflex  movements,  especially  in  the  lower  extremities,  are  excited, 
which  restore  the  foetus  to  that  position  in  which  it  enjoys  the  most 
complete  freedom  from  discomfort.  Often,  too,  the  uterine  walls  resent 
the  pressure  of  the  foetus,  and,  by  their  contractions,  serve  to  maintain 
the  body  of  the  child  in  the  uterine  axis. 

*  On  account  of  the  liver  upon  the  right  side. 

\  Vide  Schroeder's  "Handbuch  der  Geburtshiilfe,"  4te  Auflage,  p.  47. 
X  Hicks,  "  Contractions  of  Pregnant  Uterus,"  "  Obstet.  Trans.,"  p.  224. 


DEVELOPMENT  OF  THE  FCETUS. 


81 


In  cases  of  hydramnios  the  conditions  more  nearly  resemble  those 
"which  exist  in  early  pregnancy ;  hence  malpresentations  occur  with 
greater  frequency,  favored  by  the  mobility  of  the  foatus  in  the  surplus- 
age of  amniotic  fluid.  Per  contra,  when,  as  is  the  case  toward  the 
end  of  normal  pregnancies,  the  foetus  nearly  fills  the  intra-uterine 
space,  the  movements  are  very  restricted,  and  displacements  rare. 

In  primiparous  women,  the  pyriform  shape  of  the  uterus  in  the 
later  months  is  most  marked,  and  as  a  consequence  the  head  of  the 
child  is  usually  held  by  the  uterine  walls  in  the  pelvic  cavity.  In 
multiparae,  on  the  contrary,  owing  to  the  relaxation  of  the  uterine 
parietes,  it  is  usual  for  the  child,  in  obedience  to  the  laws  of  gravity,  to 
lie  somewhat  obliquely  in  the  uterus,  with  its  head  resting  upon  one  of 
the  iliac  fossae.  As  soon  as  labor  begins,  however,  the  uterine  con- 
tractions carry  the  head  to  the  axis  of  the  superior  strait  of  the  pelvis. 

The  changes  in  the  fetal  presentation  are  not,  however,  confined 
to  simple  conversions  from  an  oblique  to  an  upright  direction,  or  to 
shiftings  of  position  in  obedience  to  laws  of  gravity.  But  even  in  ad- 
vanced pregnancy  a  breech-presentation  may  become  a  head-presenta- 
tion, and  vice  versa.*  P.  Miiller  reported  a  case  in  which  the  foetus 
made  six  such  revolutions  within  five  days,  f  Now,  it  can  not  be  sup- 
posed that  the  difficulties  which  the  foetus  must  encounter  from  the 
resistance  of  the  short  transverse  diameter  of  the  uterus  could  be  over- 
come by  such  comparatively  feeble  forces  as  gravity,  or  reflex  adap- 
tive movements,  or  partial  uterine  contraction.  In  Miiller's  case  the 
changes,  if  the  mother's  story  be  correct,  must  have  taken  place,  not 
gradually,  but  suddenly,  and  by  the  vigorous  movements  of  the  child's 
limbs.  The  character  of  the  movements,  whether  sjiontaneous,  or 
reflex,  or  instinctive,  remains,  of  course,  a  question  requiring  further 
investigation. 

By  position  is  designated  the  relation  of  a  determinate  point  in  the 
body  of  the  foetus  to  the  uterine  walls.  In  head  or  breech  presenta- 
tions, the  back  of  the  child  is  most  commonly  turned  to  the  left,  which, 
hence,  is  termed  the  first  position.  The  back  turned  to  the  right  is 
known  as  the  second  position,  and  occurs  with  much  less  frequency. 

In  the  first  position  the  back  is  usually  directed  somewhat  ante- 
riorly, while  in  the  second  position  it  is  turned  rather  to  the  rear. 
In  shoulder-presentations  the  back  is  usually  directed  to  the  front. 
Changes  of  position  are  frequent  in  pregnancy,  and  take  place,  when 
other  influences  do  not  prevent,  in  obedience  to  laws  of  gravity.  When 
the  woman  stands  erect,  the  axis  of  the  uterus  is  continuous  with  the 
axis  of  the  superior  strait  of  the  pelvis,  and  forms  with  the  horizon  an 

*  ScHROEDER,  *' Schwang.  Geb.  u.  Wochenbett,"  Bonn,  186*7,  p.  21  ;  Schultze,  "Un- 
ters,  liber  den  Wechscl  der  Lage,"  etc.,  Leipsic,  1868;  Fassbender,  Berl.  "Beitrage  zur 
Geb.  und  Gynaek.,"  Bd.  i,  p.  41. 

f  ScANZONi's  "Handbuch  der  Geb.,"  4te  Auflage,  p.  123. 
6 


82 


PHYSIOLOGY  OF  PREGNANCY. 


angle  of  thirty-five  degrees.  The  uterus  does  not  occupy  exactly  the 
median  line,  but  lies  more  to  the  right.  It  is  also  twisted  slightly 
upon  its  axis,  so  that  the  left  lateral  portion  is  directed  somewhat  to 
the  front.  In  the  upright  position,  therefore,  the  anterior  wall  of  the 
uterus  not  only  forms  an  inclined  plane,  but  one,  too,  with  a  down- 
ward drop  toward  the  left  side.  Now,  if  these  relations  be  borne  in 
mind,  it  will  be  readily  seen  that  the  child,  resting  upon  the  inclined 
plane  famished  by  the  anterior  wall,  with  its  right  shoulder  look- 
ing downward,  must,  if  left  to  itself,  turn  with  its  back  to  the  left 
side  of  the  uterus.  In  the  recumbent  posture,  the  axis  of  the  ute- 
rus forms  with  the  horizon  an  angle  of  thirty  degrees,  and  the  down- 
ward slope  is  to  the  right  side.  The  child,  now  resting  upon  the 
inclined  plane  furnished  by  the  posterior  wall,  with  its  right  shoulder 
looking  downward,  would  naturally  turn  with  its  back  to  the  right 
side  of  the  uterus.  These  considerations  are  not  purely  theoretical,  as, 
when  the  conditions  have  been  such  as  to  allow  the  foetus  latitude 
of  movement,  the  changes  indicated  in  the  fetal  position  followed 
changes  in  the  attitude  of  the  mother.* 


PHYSIOLOGY  OF  PEEGl^AI^CY. 


CHAPTER  IV. 

CHANGES  EFFECTED  IN  THE  MATERNAL  ORGANISM  BY  PREGNANCY. 

Changes  in  the  sexual  appai'atus  and  neighboring  organs. — Changes  in  the  uterus. — 
Explanation  of  apparent  shortening  of  cervix. — Changes  in  the  vagina,  vulva,  ab- 
domen, navel,  breasts,  nipple. — Functional  disturbances  of  bladder. — Constipation. 
— (Edema. — Changes  effected  in  the  entire  organism. 

Changes  occukrii^g  ii^  the  Sexual  Apparatus  an^d  Neighbor- 
ing Organs. 

The  pregnant  state  is  signalized  by  the  nutritive  energy  imparted 
by  the  fecundated  ovum  to  the  generative  organs  and  to  the  viscera 
in  their  vicinity. 

The  uterus,  from  the  inception  of  pregnancy,  increases  in  vascu- 
larity. Its  mucous  membrane  becomes  soft  and  thickened.  The 
muscular  fibers  are  increased  seven  to  eleven  times  in  length,  and  three 
to  five  times  in  width.  During  the  first  five  months  new  muscular 
fibers  are  developed,  especially  upon  the  inner  layer  of  the  uterus. 

*  Honing,  Scanzoni's  "  Beitrage,"  Bd.  vii,  p.  99. 


CHANGES  IX  THE  MATERNAL  ORGANISM  BY  PREGNANCY.  83 


The  delicate  connective-tissue  processes,  between  the  muscular  fibers, 
become  more  abundant,  and,  toward  the  termination  of  pregnancy, 
display  distinct  fibrill^e.  The  vessels  increase  in  number,  length,  and 
circumference.  The  arteries,  as  we  have  noticed,  assume  a  spiral 
course,  and  in  places  communicate  directly  with  the  veins.  The  veins 
are  dilated,  and  form,  especially  in  the  placental  region,  wide-meshed 
net-works.  The  walls  of  the  veins  are  intimately  united  with  the 
muscular  walls  of  the  uterus,  and  form,  when  divided,  open-mouthed 
canals.  The  lymphatics,  starting  from  the  spongy  tissues  of  the  lin- 
ing mucous  membrane,  traverse  the  muscular  structures,  and  are 
gathered  up  by  abundant  plexuses,  which  are  distributed  especially 
over  the  fundus  and  sides  of  the  womb.  The  nerves  increase  in  length 
and  thickness,  and  grow  inward  toward  the  uterine  cavity.  Upon  the 
inner  surface  of  the  uterus  ganglia  may  be  observed.*  The  ganglion 
cervicale,  which  measures  in  the  non-pregnant  condition  three  fourths 
of  an  inch  in  length  and  one  half  an  inch  in  width,  is  now  an  inch 
and  a  half  in  breadth,  and  possesses  a  length  of  two  inches. 

These  textural  changes  are  accompanied  by  an  enormous  increase 
in  the  volume  of  the  uterus.  The  weight  of  the  latter  in  the  virgin 
state  is  about  an  ounce,  while  toward  the  end  of  pregnancy  it  weighs 
in  the  neighborhood  of  two  pounds.  The  increase  in  the  bulk  of  the 
uterus  is  progressive.  The  following  table,  by  Arthur  Farre,t  fur- 
nishes approximate  measurements  for  the  different  months  of  preg- 
nancy : 

Length.  Width. 

End  of  3d  month  4^5  inches,  4  inches. 

"     4th     ^'   5i-6     "      5  " 

"     5th     "   G  -7     "      51  " 

6th     "   8-9     "  Gh 

"     7th     "    10     "      7i  " 

"     8th     "    11     "      8  " 

"     9th     "    12     "  9 


According  to  Levret,  the  surface  of  the  virgin  uterus  measures  six- 
teen square  inches,  while  that  of  the  pregnant  uterus  at  term  measures 
three  hundred  and  thirty-nine  square  inches.  J  The  uterine  cavity  is 
stated  by  Krause  to  be  enlarged  five  hundred  and  nineteen  times.* 

The  enlargement  of  the  uterus  is  not  due,  in  the  beginning  of 
pregnancy  at  least,  to  the  pressure  of  the  expanding  ovum,  for  the 
same  changes  occur  during  the  first  four  months  in  cases  of  extra- 
uterine pregnancy.     In  the  latter  months,  however,  a  mechanical 

*  Spiegelrerw,  "  Handbuch  dor  Geburtshiilfe,"  p.  50. 

f  "  Cyclopaedia  of  Anatomy  and  Physiology,"  article  "  Uterus  and  its  Appendages,'" 
p.  645. 

X  Vide  ScAXZONi,  "  Handbuch  der  Geburtshiilfe,"  p.  11. 

*  Vide  Spiegelbero,  "  Handbuch  der  Geburtshiilfe,"  p.  51. 


84 


PHYSIOLOGY  OF  PREGNANCY. 


stretching  is  probable,  as  the  walls  become  thinned  and  conform  to 
the  size  of  the  ovum.  At  term,  the  walls  are  not  of  uniform  thickness, 
but  vary  between  one  sixth  and  one  fourth  of  an  inch. 

In  advanced  pregnancy  three  muscular  layers  are  distinctly  marked. 
They  consist  of — 1.  The  external  layer,  which  covers  the  uterus  like 
a  delicate  veil,  and  which  is  intimately  adherent  to  the  peritonaeum  ; 
2.  The  middle  layer,  which  makes  up  the  bulk  of  the  uterine  walls — | 
it  consists  of  circular  fibers  surrounding  the  vessels,  and  circular  and 
longitudinal  fibers,  which  interlace  with  one  another  ;  3.  The  inner 
layer,  composed  mainly  of  circular  muscular  fibers,  which  form  con- 
centric rings  about  the  orifices  of  the  tubes  and  os  internum.*  The 
third,  like  the  first  layer,  is  feebly  developed.  The  existence  of  a  dis- 
tinct sphincter  muscle  at  the  os  internum  is  admitted  by  many  anat- 
omists, and  questioned  by  others.  The  clinical  evidence  in  its  favor 
is  strong.  According  to  Kreitzer's  investigations,  the  muscular  fibers 
around  the  os  internum  in  all  the  layers  have  a  more  or  less  transverse 
direction,  f 

With  the  growth  of  the  gravid  uterus,  the  peritoneal  coat  put 
upon  the  stretch,  and,  in  places,  a  thickening  of  the  serous  membrane 
takes  place  by  the  formation  of  new  tissue-elements.  At  the  same 
time,  the  folds  of  the  broad  ligaments  gradually  separate,  so  that 
toward  the  end  of  pregnancy  the  ovaries  and  Fallopian  tubes  are  in 
close  contact  with  the  uterus. 

The  growth  of  the  uterus  is  confined  chiefly  to  the  body,  the  cervix 
participating  only  to  a  slight  extent.  In  the  early  months,  the  in- 
crease is  rather  in  the  antero-posterior  and  lateral  diameters  than  in 
the  longitudinal  diameter.  As  a  consequence,  it  is  not  until  the 
fourth  mpnth,  at  which  time  the  uterus  is  nearly  of  the  size  of  a  man's 
head,  that  the  fundus  can  be  felt  through  the  abdominal  walls  above 
the  symphysis  pubis.  In  these  earlier  months  the  normal  anteflexion  of 
the  uterus  is  increased  by  the  weight  of  the  corpus  uteri.  In  the 
fifth  month  the  uterus  fills  the  hypogastrium,  and  in  the  ninth  month 
reaches  the  epigastrium.  During  the  last  two  weeks,  however,  the 
uterus  sinks  somewhat  into  the  pelvic  cavity.  At  the  same  time  the 
fundus  of  the  uterus  sinks  downward  and  forward,  so  as  to  stand 
about  three  lines  beneath  the  lower  extremity  of  the  sternum. 

In  the  upright  posture  the  uterus,  in  advanced  pregnancy,  rests 
upon  the  anterior  abdominal  walls.  As,  in  the  intervals  of  contrac- 
tion, the  uterus  is  a  mere  sac  with  fluid  contents,  it  becomes  flattened 
from  side  to  side,  and  the  width  increases  at  the  expense  of  the  dis- 

*  For  a  minute  description  of  the  intricate  arrangement  of  the  muscular  fibers  in  the 
dilferent  layers  of  the  uterus,  vide  Helie,  "  Ilechcrches  sur  les  dispositions  des  fibres 
musculeuses  dc  I'uterus  devellopees  par  la  grosscsse,"  Paris,  1864. 

f  Krfitzer,  "  Anat.  Unters.,  iiber  die  Musculatur  der  nicht  schwangern  Gebarmut- 
tcr,"  "St.  Petersb.  med,  Ztschr.,"  1871,  Heft  ii,  p.  113. 


CHANGES  IX  TEE  MATERNAL  ORGANISM  BY  PREGNANCY. 


85 


tance  from  the  fundus  to  the  symphysis  pubis.  In  the  horizontal 
position,  in  which  the  uterus  rests  upon  the  vertebral  column,  its 
length  is,  on  the  contrary,  increased  and  its  width  diminished.  In 
the  upright  position,  the  intestines  occupy  the  space  posterior  to  the 
uterus.  In  the  dorsal  position,  the  intestines  lie  chiefly  upon  the 
sides,  but  partly  too  in  front  of  the  uterus. 

During  the  first  three  months  of  pregnancy,  the  pyriform  shape 
of  the  uterus  is  preserved.  During  the  succeeding  three  months,  ow- 
ing to  the  relative  increase  in  the  lateral  and  antero-posterior  diameters, 
the  body  gradually  assumes  the  appearance  of  a  flattened  spheroid. 
After  the  sixth  month  the  longitudinal  diameter  again  preponderates. 

As  the  dilatation  of  the  uterus  takes  place  more  rapidly  in  its  upper 
than  in  its  lower  segment,  the  cavity  of  the  organ  assumes,  under 
normal  conditions,  an  oval  shape,  with  the  narrow  end  pointing  down- 
ward, corresponding  to  the  ovoid  shape  of  the  foetus  in  head-presenta- 
tions. It  was  long  taught  and  believed  that  this  change  of  shape, 
occurring  in  the  latter  months  of  pregnancy,  was  due  to  the  gradual 
unfolding  of  the  cervix  uteri  from  above  dov/nward,  which  thus  con- 
tributed to  the  enlargement  of  the  uterine  cavity.  It  is,  however, 
probable  that,  with  rare  exceptions,  the  cervix  uteri  maintains  its  com- 
plete integrity  up  to  the  commencement  of  labor.  The  enlargement 
of  the  uterus,  necessitated  by  the  development  of  the  foetus,  results 
chiefly  from  the  growth  and  distention  of  the  fundus  and  posterior 
uterine  wall.* 

The  cervix  uteri  participates  in  the  hypertrophy  of  the  entire 
uterus.  Its  development,  however,  is  completed  by  the  fourth  month, 
and  is  the  result  not  so  much  of  increased  growth  or  new  formation 
of  tissue-elements  as  of  the  loosening  of  its  structure  and  swelling 
from  serous  infiltration.  This  latter  is  the  consequence  of  a  hypersemia 
of  the  cervix,  which  results  from  the  passive  relaxation  and  dilatation 
of  the  cervical  vessels.  It  occasions  a  physiological  softening  of  the 
tissues,  which  first  manifests  itself  in  those  portions  of  the  cervix 
where  the  least  resistance  is  encountered,  viz.,  beneath  the  mucous 
membrane  beginning  at  the  os  externum,  extending  outward  through 
the  muscular  structures  of  the  vaginal  portion,  and  afterward  upward 
toward  the  os  internum,  f  The  follicles  of  the  cervical  mucous  mem- 
brane furnish  a  thickened  secretion,  which  fills  the  cervical  canal,  and 
forms  what  is  known  as  the  mucous  plug."  Frequently  the  orifices 
of  the  follicles  become  occluded.  The  follicular  sacs  then  fill  with 
their  own  secretion,  and  project  from  the  mucous  surface  as  the  ovules 
of  Naboth.  Erosions  about  the  os  externum  are  rarely  absent  in  ad- 
vanced pregnancy. 

*  For  the  contrary  view,  maintained  by  Bandl,  vide  note,  p.  28,  article  "  Labor." 
f  LoTT,  "Zur  Anatomic  und  Physiologic  des  Cervix  Uteri,"  Erlangen,  1872,  pp 
35,  36. 


80 


PHYSIOLOGY  OF  PREGNANCY. 


With  the  advance  of  pregnancy  an  apparent  shortening  of  the  cer- 
yix  takes  place,  at  first  confined  to  the  vaginal  portion,  but  afterward 
involving  the  entire  organ.  The  earlier  explanation  of  this  phenomenon, 
and  one  which  still  meets  with  very  general  acceptance,  assumes  that, 
after  the  sixth  month,  a  gradual  unfolding  of  the  cervix  from  above 
downward  takes  place,  which  contributes  to  the  enlargement  of  the 
uterine  cavity.  In  this  manner  space  is  provided  in  correspondence 
with  the  rapidly  increasing  growth  of  the  foetus.  The  strength  of 
this  doctrine  lay,  in  a  great  measure,  in  the  seemingly  confirmatory 
evidence  afforded  by  digital  explorations. 

In  opposition  to  the  current  opinion,  Stoltz,  in  his  inaugural  thesis, 
published  in  1826,*  maintained  that  the'  internal  os  remained  closed  up 
to  the  last  two  weeks  preceding  delivery,  when,  indeed,  under  the  in- 
fluence of  painless  contractions,  the  effacement  of  the  cervix,  described 
by  earlier  writers,  did  in  fact,  at  least  in  primiparae,  take  place.  Stoltz 
explained  the  apparent  shortening  of  the  cervix  as  the  result  of  a 
spindle-shaped  dilatation  of  the  cervical  canal,  causing  an  approxima- 
tion of  the  external  and  internal  orifices.  In  1859  Duncanf  furnished 
corroborative  evidence  of  the  general  correctness  of  Stoltz's  view,  by 
means  of  two  dissections  of  uteri  derived  from  women  who  died  re- 
spectively in  the  seventh  and  eighth  months  of  pregnancy.  In  these 
cases  the  length  of  the  cervix  uteri  had  undergone  little  or  no  change 
consequent  upon  pregnancy.  Duncan,  however,  in  common  with 
Stoltz,  admitted  that,  during  the  latter  days  of  gestation,  incipient 
uterine  contractions  of  a  painless  nature  may  lead  to  the  opening  of 
the  internal  os.  In  1863  he  showed  that  Stoltz's  discovery  had  been 
anticipated  by  Weitbrecht  in  1750.  +  In  1862  Professor  I.  E.  Taylor,* 
of  New  York,  stated,  what  is  without  doubt  true  in  the  majority  of 
cases,  that  the  cervix  remained  closed,  and  retained  its  entire  length  up 
to  the  very  beginning  of  active  labor.  In  evidence  he  offered  the  re- 
sults of  four  post-mortem  examinations  made  upon  woriien  dying  from 
accidental  causes  during  the  first  stage  of  labor.  ||  In  1873  I  found  in 
the  dissecting-room  a  woman,  seven  months  pregnant,  who  had  died 
in  the  first  stage  of  labor,  but  after  dilatation  of  the  cervix  had  well 
advanced.  The  bag  of  waters,  in  the  form  of  a  cylindrical  sac  two 
inches  in  diameter,  protruded  into  the  vagina.  Both  the  cervical 
orifices  were  distinctly  defined  ;  the  cervix  was  equally  expanded 
throughout  its  entire  extent ;  and  the  head  rested  above  the  os  inter- 
num.   The  cervix  clearly  formed  no  part  of  the  uterihe  cavity,  but 

*  "  Sur  les  difforents  etats  dii  col  dc  I'literus,  mais  principalement  sur  les  changemcnts 
que  la  gestation  ct  I'accouchemcnt  lui  font  eprouvcr,"  Strasbourg,  1826. 

•)•  "On  the  Cervix  Uteri  in  Pregnancy,"  "  Edinburgh  Med.  Jour.,"  vol.  iv,  1859,  p.  774. 
X  Vide  "Edinburgh  Med.  Jour.,"  September,  18G3. 

#  Taylor,  "  On  the  Cervix  Uteri,"  "Am.  Med.  Times,"  June  21,  1862. 

I  Vide  likewise  case  of  Angus  McDonald,  in  "Edinburgh  Med.  Jour.,"  April,  1877. 


CHANGES  IN  THE  MATERNAL  ORGANISM  BY  PREGNANCY.  87 

served  merely  as  a  communicating  passage  between  the  uterus  and 
vagina.  Dr.  Taylor  has  made  some  very  interesting  observations  upon 
the  action  of  the  cervix  during  labor,  using  for  the  purpose  a  large 


Fig.  66. — Appearance  of  vaginal  portion  in  primipara ;  end  of  ninth  month.  (Taylor.) 

(three  to  three  and  a  half  inch)  cylindrical  speculum,  by  means  of 
which  the  entire  process  can  be  freely  witnessed.  In  multi parous  women 
he  has  seen  the  head  descend  during  a  pain  so  as  to  produce  complete 
obliteration  of  the  cervix,  and  then  recede,  leaving  the  latter  with  the 
same  appearances  as  existed  previous  to  labor.* 

While  the  non-shortening  of  the  cervix  has  been  fairly  demon- 
strated, it  is  not  so  clear  that  the  os  internum  remains  closed  in  all 
cases  up  to  the  beginning  of  labor.  Certainly  there  are  rare  excep- 
tions to  the  rule.  Litzmann  f  reported  a  case  in  which  the  mem- 
branes were  found,  at  the  time  of  labor,  attached  to  the  cervical  wall 
around  the  periphery  of  the  os  externum.  In  a  few  instances  I  have 
had  an  opportunity,  during  the  last  period  of  pregnancy,  to  deter- 
mine by  touch  the  dilatation  of  the  os  internum.  The  cervix,  how- 
ever, did  not  expand  in  such  a  way  as  to  become  continuous  with  the 
uterine  cavity,  but  remained  distinct  and  apart,  preserving  its  inde- 
pendent existence.  How  far  such  a  dilatation  is  due  to  painless  labor 
it  is  impossible  to  say.    Miiller  I  regards  it  rather  as  the  result  of  the 

*  "Med.  Record,"  October  13,  18Y7. 

f  "  Das  Verhalten  des  Cervix  Uteri  in  der  Schwangerschaft,"  "Arch.  f.  Gynaek.,"  Bd. 
X,  p.  130. 

X  "  Untersuchungen  iiber  die  Verkiirzung  der  Vaginalportion  in  den  Ictzten  Monaten 
der  Graviditat  " :  Scanzoni's  "  Bcitrage,"  Bd.  v,  H.  2,  1869,  pp.  306  et  seq.  Miiller  does 
not,  however,  exclude  the  possible  action  of  uterine  contractions. 


88 


PHYSIOLOGY  OF  PREGNANCY. 


pressure  of  the  head  upon  the  softened  cervix.  I  had  once  occasion 
to  examine  a  multipara  toward  the  end  of  gestation,  to  determine  the 
question  as  to  the  safety  of  her  making  a  railroad  journey  to  a  neigh- 
boring city.  I  found  the  head  low,  the  cervix  soft,  and  the  os  inter- 
num clearly  dilated  to  the  size  of  a  dollar.  Two  weeks  later  I  was 
called  to  see  her  in  the  early  stage  of  labor,  and  found,  under  the 
influence  of  the  uterine  contractions,  the  canal  of  the  cervix  had 
again  closed. 

The  apparent  shortening  of  the  cervix  is  unquestionably  due  in 
part  to  the  swelling,  incident  to  pregnancy,  of  the  vaginal  mucous 
membrane,  and  of  the  vascular,  loose-meshed  tissues  surrounding  the 
cervix  at  the  vaginal  junction.  But,  in  addition,  a  noticeable  differ- 
ence may  be  observed  between  cases  in  which  the  head  occupies  the  pel- 
vis and  those  in  which  it  rests  upon  an  iliac  fossa.  In  the  latter  the 
cervix  is  found,  both  by  the  speculum  and  by  the  touch,  to  have  pre- 


FiG.  67. — Appearance  of  cervix  in  multipara;  ninth  month.  (Taylor.) 


served  its  entire  length.  In  the  former,  on  the  contrary,  the  anterior 
lip  is  often  obliterated,  while  the  length  of  the  canal  and  the  posterior 
cervical  wall  remain  unchanged. 

In  explanation  of  this  phenomenon,  it  is  to  be  borne  in  mind  that 
in  the  upright  position  the  uterus  forms  with  the  horizon  an  angle  of 
thirty  degrees.  The  weight  of  the  ovum,  resting  upon  the  inclined 
plane  of  the  uterus,  increases  the  convexity  of  the  anterior  wall,  and 
the  head  of  the  foetus,  when  it  enters  the  pelvic  cavity,  does  not  fall 
directly  upon  the  os  internum,  but  somewhat  in  front,  producing,  in 
accordance  with  the  laws  of  gravity,  a  bulging  of  the  anterior  lower 
segment.    Upon  vaginal  examination  the  head  is  felt,  therefore,  low 


CHANGES  m  THE  MATERNAL  ORGANISM  BY  PREGNANCY.  89 

down,  and  covered  by  the  uterine  walls,  while  the  cervix  is  directed 
backward,  not  always  in  the  median  line,  and  is  often  reached  with 
difficulty,  because  the  finger,  in  passing  to  it,  has  first  to  make  the 


Fig.  68.— Showing  the  convexity  of  the  anterior  wall  produced  by  the  weight  of  the  ovum. 

circuit  of  the  child's  head.  The  bulging,  produced  by  the  latter, 
effaces  the  angle  between  the  anterior  lip  and  the  vaginal  wall,  while 
the  posterior  lip  remains  unchanged.  The  canal  of  the  cervix  assumes 
a  nearly  vertical  direction,  and  when  examined  with  care,  with  due 
regard  to  the  physiological  softening  of  its  tissues,  is  found  to  have 
preserved  its  normal  length.  By  pushing  the  head  away  from  the 
cervix,  or  by  placing  the  patient  in  the  knee-elbow  position,  so  as 
to  allow  the  head  to  recede,  the  anterior  lip  resumes  its  normal  di- 
mensions.* 

In  the  vagina  changes  take  place  corresponding  to  those  in  the 
uterus,  though,  of  course,  less  in  degree.  The  smooth  muscular  fibers 
hypertrophy ;  the  vessels  of  the  venous  plexus  increase  in  size  and  im- 
part a  blue  color  to  the  vaginal  walls  ;  the  mucous  membrane  becomes 
thickened,  and  furnishes  a  more  abundant  secretion.  The  mucous 
membrane  likewise  increases  in  length,  so  that,  in  spite  of  the  fact  that 
it  is  lifted  upward  by  the  elevation  of  the  uterus,  the  anterior  vaginal 
wall  not  unfrequently  protrudes  from  the  vulva.  The  papillae  swell 
and  impart  a  granular  feel  to  the  finger. 

The  vulva  becomes  turgescent,  the  labia  gape  apart,  to  the  mucous 

*  P.  MuLLER,  op.  cit.,  p.  342. 

LoTT,  "  Verhaltcn  dcs  Cervix  Uteri  wiihrend  der  Scliwangerschaft,"  p.  71. 

I.  E.  Taylor,  "  Non-shortening  of  the  Cervix  during  Gestation,"  "  Med.  Record," 
October  13,  1877,  p.  646,  with  verbal  statement  of  the  author  concerning  the  results  of 
his  examinations  of  pregnant  women  in  the  genu-pectoral  position. 


90 


PHYSIOLOGY  OF  PREGNANCY. 


surface  the  enlargement  of  the  veins  and  venous  plexuses  gives  a 
dusky  hue,  and  the  follicles  secrete  abundantly. 

The  connective  tissue  between  the  layers  of  the  broad  ligaments 
and  around  the  uterus  becomes  succulent  from  serous  infiltration. 
The  lymphatics,  which  convey  away  the  waste  engendered  by  the  rapid 
tissue-changes  in  the  pelvic  organs,  enlarge  in  conformity  with  the 
increased  labor  thrown  upon  them.  The  hips  broaden  from  the  de- 
posit of  fat  in  the  subcutaneous  tissue  of  the  entire  pelvic  region. 


Fig.  69. — Diagram  representing  changes  in  the  cervix  resulting  from  pressure  of  child's  head 

on  anterior  wall.  (Lott.) 

With  the  growth  of  the  uterus  the  abdominal  walls  are  put  upon 
the  stretch,  and,  in  well-nourished  individuals,  are  increased  in  thick- 
ness, by  the  more  abundant  formation  of  adipose  tissue.  By  the  fifth 
month  the  navel  begins  to  diminish  in  depth,  and  about  the  seventh 
month  becomes  level  with  the  skin.  During  the  last  two  months  the 
navel  often  is  everted  by  the  pressure  of  the  uterine  tumor,  and  forms 


CHANGES  IN  THE  MATERNAL  ORGANISM  BY  PREGNANCY.  91 


a  rounded  elevation.  Another  consequence  of  the  stretching  of  the 
abdominal  walls  is  the  formation  of  reddish,  bluish,  and  at  times  of 
white  glistening  streaks  (striae),  which  do  not  disappear  after  delivery, 
though  they  lose  their  coloring.  They  rarely  fail  in  the  last  third  of 
pregnancy.  They  are  found  most  abundant  upon  the  lower  half  of 
the  abdomen,  especially  upon  the  sides,  where  they  form  curved,  sinu- 
ous lines.  They  are  due  to  an  atrophic  condition  of  all  the  skin-lay- 
ers, to  partial  obliteration  of  the  lymph-spaces,  and  to  a  condensation 
of  the  connective-tissue  elements,  which,  in  place  of  forming  rhomboid 
meshes,  run  parallel  to  one  another.*  Striae  are  j^roduced  likewise  in 
pathological  distentions  of  the  abdomen,  and  are  not  peculiar  to  preg- 
nancy. Similar  streaks  form  upon  the  nates  and  upon  the  anterior 
and  posterior  surfaces  of  the  thighs.  They  may  occur,  too,  indepen- 
dent of  pregnancy,  as  in  the  rapid  development  of  the  hips  at  puberty. 
Painful  sensations  at  the  costal  insertions  of  the  abdominal  muscles 
are  often  experienced  during  pregnancy.  They  occur  more  commonly 
in  multiparae,  and,  owing  to  the  preponderance  of  the  right  lateral 
position  of  the  uterus,  with  greater  frequency  upon  the  right  side. 
Sometimes  the  recti  muscles  are  separated  from  one  another.  This  is 
specially  liable  to  take  place  in  contracted  pelves,  and  in  women  of 
small  stature,  in  whom,  on  account  of  the  insufficient  longitudinal 
diameter  of  the  abdominal  cavity,  the  uterus  is  forced  to  make  for 
itself  the  space  requisite  for  its  development  to  term  at  the  expense  of 
the  abdominal  walls. 

The  mammary  glands,  previous  to  gestation,  are  firm  and  nearly 
hemispherical.  During  pregnancy  the  breasts  increase  in  volume,  and 
present  characteristic  changes  in  structure  and  consistence.  These 
changes  are  due  to  a  swelling  of  the  connective  tissue  of  the  organ, 
the  development  of  glandular  acini  along  the  course  of  the  lactiferous 
ducts,  and  the  increased  deposition  of  fat  betiveen  the  lobes.  The 
enlargement  of  the  breast  often  begins  in  the  second  month,  and  be- 
comes noticeable  between  the  fourth  and  fifth  months  of  gestation. 
With  the  development  of  the  glandular  structure  the  breasts  possess  a 
knotty,  uneven  feel,  more  marked  at  first  about  the  periphery  of  the 
organ,  and  thence  proceeding  gradually  toward  the  nipple.  The  veins 
enlarge,  and  form  a  tracery  beneath  the  skin.  Early  in  pregnancy, 
fullness  of  the  breasts,  and  pains,  shooting  toAvard  the  axilla,  are  often ' 
experienced.  As  the  breasts  increase  in  size,  the  cutis  yields  in  many 
women  about  the  periphery,  where  the  tension  is  greatest,  whereby 
bluish,  white,  or  reddish  lines,  like  those  remarked  upon  the  abdomen 
and  thighs,  make  their  appearance. 

The  nipple  becomes  elongated,  is  more  sensitive,  and  enters  readily 
into  an  erectile  condition.    Changes  in  the  areola  are  justly  regarded 

*  BusEY,  "  The  Cicatrices  of  Pregnancy,"  "  Trans,  of  the  Am.  Gynaec.  Soc,"  vol.  iv,  p. 


92 


PHYSIOLOGY  OF  PREGNANCY. 


as  among  the  most  important  evidences  of  the  existence  of  pregnancy. 
Often  as  early  as  the  second  month  the  areola  has  a  soft,  cedematous 
feel,  and  is  raised  ahove  the  level  of  the  surrounding  skin.  The  seba- 
ceous follicles,  ten  to  twenty  in  number,  enlarge,  and  bedew  the  sur- 
face with  moisture.  By  the  middle  of  pregnancy  a  circle,  due  to  pig- 
mentary deposit,  is  formed  around  the  nipple,  the  coloration  of  which 
depends  in  part,  though  not  altogether,  upon  the  complexion  of  the 
individual,  being  usually  more  intense  in  brunettes  than  in  women 
with  fair  hair  and  delicate  skins.  In  the  negress  the  areola  is  jet- 
black,  while  in  the  albino  it  is  of  a  delicate  rose-color  (Montgomery). 
The  diameter  of  the  pigmented  circle  averages  from  an  inch  to  an  inch 
and  a  half,  though  it  sometimes  greatly  exceeds  the  figures  mentioned. 
In  the  latter  part  of  pregnancy  there  often  forms  around  the  outer  part 
of  the  areola  a  so-called  secondary  areola,  consisting  of  scattered  round 
spots,  presenting  the  appearance  as  though,  to  use  the  language  of 
Montgomery,  the  color  had  been  discharged  by  a  shower  of  drops. 
This  peculiarity  is  due,  for  the  most  part,  to  the  presence  of  enlarged, 
non-pigmented  sebaceous  follicles. 

The  pressure  of  the  gravid  uterus  gives  rise  to  functional  disturb- 
ances in  the  neighboring  organs  of  the  pelvic  cavity.  The  capacity 
of  the  bladder  is  diminished,  and,  as  a  consequence,  increased  fre- 
quency of  urination  results.  In  some  women,  when  the  bladder  is 
moderately  full,  the  mere  act  of  coughing  or  sneezing,  or  the  upright 
posture,  produces  involuntary  discharges  of  water.  Constipation  is 
common,  due  not  so  much,  however,  to  mechanical  obstruction  as  to 
diminished  intestinal  action.  In  the  latter  months  of  pregnancy, 
pressure  on  the  sacral  nerves  gives  rise  at  times  to  numbness  of  the 
extremities,  neuralgic  pains,  cramps,  and  hindered  locomotion.  (Ede- 
ma of  the  lower  half  of  the  body  and  varicose  dilatation  of  the  veins 
of  the  legs,  the  rectum,  and  vulva,  are  referable  partly  to  pressure  and 
partly  to  the  increased  vascular  fullness  of  the  pelvic  vessels  induced 
by  pregnancy. 

ChAKGES  effected  IK  THE  ENTIRE  ORGANISM. 

Corresponding  to  the  enormous  development  of  the  vascular  ap- 
paratus in  the  gravid  uterus,  there  is  an  increase  in  the  total  quantity 
of  blood  in  the  circulation.*  Thus  a  sort  of  plethora  is  formed,  which, 
however,  is  serous  in  character.  The  red  blood  corjiuscles,  the  albu- 
men, the  iron,  and  the  salts  of  the  blood  are  diminished,  while  the 
white  blood  corpuscles,  the  fibrine,  and,  above  all,  the  water  of  the 
blood,  are  increased.    These  changes  are  explained,  in  part  at  least,  by 

*  This  assertion,  which  is  simply  the  formal  statement  of  a  physiological  necessity, 
has  been  experimentally  proved  to  be  correct  in  bitches  by  Spiogelberg  and  Gschcidlin. 
Vide  *'  Untersuchungen  iiber  die  Blutmenge  triichtigcr  Hiinde,"  "  Arch.  f.  Gynaek.,"  Bd. 
iv,  p.  112. 


CHANGES  IN  THE  MATERNAL  ORGANISM  BY  PREGNANCY.  93 


the  demands  made  upon  the  maternal  system  by  the  growing  fa3tus. 
With  increased  waste  in  the  organism,  as  evidenced  by  an  augmenta- 
tion in  the  carbonic  acid  and  urea  eliminated,  there  is  usually  dimin- 
ished capacity  to  take  and  assimilate  food.  How  far  these  causes  are 
operative  in  producing  the  above-mentioned  conditions  is  shown  by  the 
slight  degree  of  hydrasmia,  or  the  entire  absence  of  blood  impoverish- 
ment, in  women  who  possess  during  pregnancy  good  appetites  and 
excellent  digestions,  and  who,  at  the  same  time,  are  able  to  procure  an 
abundance  of  nutritious  food.* 

As  a  necessary  corollary  to  the  increase  of  the  total  blood-supply 
in  pregnant  women,  the  maintenance  of  the  circulation  would  require 
either  greater  frequency  in  the  contractions  of  the  heart,  or  that  the 
entire  quantity  of  blood  entering  the  ventricles  during  the  diastole 
should  be  increased.  Now,  it  is  known  that  the  frequency  of  the  pulsa- 
tions of  the  heart  remains  unchanged.  For  the  alternate  contingency, 
however,  the  dilatation  of  the  cavities  becomes  a  necessity.  For  the 
same  reason  the  arterial  tension  is  increased,  imparting  a  fullness  to 
the  pulse,  which  was  formerly  regarded  as  an  indication  for  venesec- 
tion. The  interposition  of  the  enlarged  and  multiplied  vascular  chan- 
nels in  the  pelvic  organs  increases  the  labor  thrown  upon  the  heart,  in 
response  to  which  an  eccentric  hypertrophy  of  the  left  ventricle  takes 
place,  f 

Pregnancy  increases  the  size  of  the  thyroid  gland.  In  districts 
where  goitre  is  endemic,  and  in  women  in  whom  a  predisposition  al- 
ready exists,  pregnancy  may  produce  a  temporary  form  of  the  disease, 
or  furnish  the  starting-point  of  the  permanent  affection.  I 

In  rather  more  than  half  the  cases  of  pregnancy,  thin  bone-like 
lamellae,  consisting  chiefly  of  phosphate  and  carbonate  of  lime,  meas- 
uring from  one  sixth  to  one  half  a  line  in  thickness,  are  found  deposited 
upon  the  inner  surface  of  the  skull.  These  plates  have  been  termed 
osteophytes  by  Eokitansky.  They  occur  after  the  third  month,  and 
are  found  chiefly  upon  the  frontal  and  parietal  bones,  especially  along 
the  course  of  the  sulcus  falciformis  and  the  arteria  meningea  media.^ 

We  have  already  noticed  the  increase  in  the  carbonic  acid  discharged 
by  the  lungs  during  pregnancy.  Andral  and  Gavariet  found  the  mean 
consumption  of  carbon  hourly  in  pregnant  women  equaled  8  grammes 

*  IIasse,  "  Das  Blut  dcr  Sehwangeren,"  "  Arcb.  f.  Gynaek,,"  Bd.  x,  p.  351.    Vide  ibid., 
for  new  experiments  relative  to  the  diminution  in  the  salts  and  iron  (hsematin)  of  the' 
blood,  and  for  facts  relative  to  increased  destructive  assimilation. 

f  For  the  results  of  Larcher  and  other  French  investigators  upon  this  point,  vide 
Joulin,  "  Traite  complct  d'accouchement,"  p.  383. 

X  L.  Tait,  "  Enlargement  of  the  Thyroid  Body,"  "  Obstet.  Jour,  of  Gr.  Brit,  and  Ire.," 
June,  1875. 

*  FoiiSTER,  "  Ilandbuch  der  patholog.  Anat.,"  Bd.  ii,  p.  945.  These  osteophytes  are 
not  peculiar  to  pregnancy ;  they  likewise  occur  commonly  in  consumptives.  "  Nouveau 
Diet,  de  Chir.  et  de  Med.,"  t.  xvii.  Art.  "  Grosscsse." 


94 


PHYSIOLOGY  OF  PREGNANCY. 


instead  of  6*4  grammes,  as  in  menstruating  women.  The  thorax  is 
increased  in  breadth  and  diminished  in  depth,  a  condition  which 
becomes  reversed  after  delivery.  There  is  usually,  toward  the  end  at 
least,  a  diminution  in  the  vital  capacity  of  the  lungs.*  Subjectively, 
there  is  often  experienced,  especially  in  primiparse,  a  sense  of  oppressed 
respiration  during  the  latter  months  of  pregnancy.  This  feeling  is 
relieved,  however,  to  a  considerable  extent,  when  the  uterus,  in  the 
last  two  to  three  weeks  of  pregnancy,  sinks  downward  and  forward. 

Very  few  pregnant  women  escape  altogether  troubles  of  digestion  ; 
of  these  the  most  common  are  nausea  and  vomiting,  due  to  spasmodic 
contractions  of  the  stomach  and  diaphragm.  The  nausea  and  vomit- 
ing usually  occur  on  waking  in  the  morning,  i.  e.,  with  an  empty 
stomach,  more  rarely  after  meals.  In  a  few  cases,  these  gastric  dis- 
turbances take  place  only  three  or  four  times  in  the  beginning  of 
l^regnancy,  upon  the  first  suppression  of  the  menses.  Usually,  how- 
ever, they  recur  daily  during  the  first  three  months,  and  then  gradu- 
ally disappear.  In  the  early  period  of  pregnancy,  the  appetite  is,  as 
a  rule,  capricious,  like  that  of  chlorotic  women.  Some  are  said  to 
crave  unusual  and  even  disgusting  articles  of  food  (longings).  An 
increased  secretion  of  the  salivary  glands  is  often  a  noticeable  symptom. 
The  bowels  are  more  commonly  constipated.  In  a  few,  however,  diar- 
rhoea takes  place,  often  about  the  time  of  the  month  when  the  woman 
would,  if  not  pregnant,  have  her  menstrual  flow. 

It  is  not  surprising  that  in  the  first  three  months  of  pregnancy 
many  women  lose  their  flesh  and  color,  have  dark  circles  about  their 
eyes,  and  wear  a  drawn,  haggard  look ;  but  after  the  third  month,  or 
later,  after  fetal  movements  have  been  felt,  the  appetite  returns,  the 
digestion  becomes  more  active,  the  nutrition  is  improved,  and  an  in- 
crease of  weight  in  normal  cases  takes  place,  which  can  not  be  accounted 
for  simply  by  the  growth  of  the  ovum.  According  to  Gassner's  esti- 
mates, the  average  gain  in  the  eight  months  amounts  to  five  and  a 
half  pounds,  in  the  ninth  month  to  three  and  a  half  pounds,  and  in 
the  tenth  month  to  about  three  and  a  quarter  pounds.  The  total 
increase  he  found  not  far  from  one  thirteenth  of  the  entire  weight  of 
the  body,  f 

We  have  already  noticed  the  pigmentation  of  the  areola  in  speaking 
of  the  changes  produced  in  the  breasts  of  pregnancy.  The  forehead 
likewise  at  times  becomes  covered  with  dirty-looking  brownish  patches, 

*  Dohrn  found  that  in  sixty  per  cent,  there  was  a  marked  diminution  in  the  vital  ca- 
pacity of  the  lungs  of  women  in  the  latter  part  of  pregnancy,  as  compared  with  that  of 
the  same  women  tested  twelve  to  fourteen  days  after  delivery.  "  Zur  Kcnntniss  der 
Einflusses  von  Schwangerschaft  und  Wochenbett  auf  die  vitale  Capacitat  der  Lungen," 
"Monatsschr.  f.  Geburtsk.,"  Bd.  xxviii,  18G6,  p.  457.  Earlier  observations,  not  entirely 
in  accord  with  those  of  Dohrn,  were  made  by  Fabius  and  Wintrich.  Vide  Spiegelberg, 
"Lehrbuch  der  Geburtshulfe,"  1877,  p.  63. 

f  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xix,  p.  1. 


THE  DIAGNOSIS  OF  PREGNAXCY. 


95 


wliicli  may  extend  over  the  entire  face,  especially  over  the  eyelids,  the 
root  of  the  nose,  and  the  upper  lip.  These  spots,  with  the  disfigure- 
ment they  occasion,  rarely  remain  permanent,  but,  as  a  rule,  disap- 
pear shortly  after  confinement.  Similar  discolorations  are  often  ob- 
served about  the  external  organs  of  generation,  upon  the  abdomen, 
and,  with  considerable  constancy,  along  the  linea  alba  and  around  tlie 
umbilicus. 

Owing  to  the  increased  arterial  tension,  the  urine  is  more  abundant 
and  watery.  Albumen  in  the  urine  is  not  an  infrequent  occurrence, 
due,  probably,  in  the  milder  cases,  to  transitory  catarrhal  affections 
of  the  bladder.* 

The  nervous  system  becomes  more  impressionable.  The  whole 
character  frequently  undergoes  a  change.  The  most  amiable  of  women 
are  liable  to  become  fretful,  peevish,  and  unreasonable.  The  spirits 
are  often  depressed,  es^DCcially  in  the  earlier  months,  when  the  general 
nutrition  is  most  impaired.  The  melancholia  in  women  already  pre- 
disposed to  insanity  may  terminate  in  mania.  The  memory  is  gen- 
erally weakened,  especially  in  women  who  have  borne  a  number  of 
children  in  rapid  succession.  On  the  other  hand,  nervous  women 
sometimes  lose  their  nervousness,  and,  exceptionally,  there  are  individ- 
uals who  experience  during  j^regnancy  a  peculiar  sense  of  well-being. 
Neuralgic  affections  are  common  (face-ache,  toothache,  etc.)  ;  local 
anaesthesia  and  paresis  occur  at  times  ;  the  senses  are  often  disordered 
(nyctalopia,  amaurosis,  amblyopia,  deafness,  perversions  of  taste  and 
smell)  ;  pruritus  i^  sometimes  troublesome  ;  and,  finally,  pregnant 
women  are  subject  to  attacks  of  dizziness  and  syncope. 


CHAPTER  V. 

THE  DIAGNOSIS  OF  PREGNANCY. 

Signs  of  pregnancy. — Suppression  of  menses. — Nausea. — Salivation. — Breasts. — Increase 
of  abdomen, — Changes  of  the  os  and  cervix. — Quickening. — Ballottement. — Fetal 
heart-beat. — Uterine  bruit. — Funic  souffle. — Interrogation  of  the  patient. — Methods 
of  physical  examination. — Inspection  of  abdomen. — Palpation. — Auscultation. — The 
vaginal  touch. — Distinction  between  first  and  subsequent  pregnancies. — Diagnosis  of 
death  of  foetus. — Duration  of  pregnancy. — Prediction  of  day  of  confinement  from 
date  of  last  menstruation. — Date  of  quickening. — Size  of  uterus. 

A  THOROUGH  familiarity  with  all  the  signs  which  lead  us  to  the 
recognition  of  pregnancy  is  an  essential  part  of  the  outfit  of  every 
practicing  physician.    The  reasons  for  this  are  obvious.    Mistakes  as 

*  Kaltenbach,  "  Ueber  Albuminuric  und  Erkrankungen  der  Harnorgane  in  der  Fort- 
pflanzungspcriode,"  "Arch.  f.  Gynaek.,"  Bd.  iii,  p.  1. 


96 


PHYSIOLOGY  OF  PREGNANCY. 


to  the  diagnosis  of  the  pregnant  state  can  neA^er  be  covered  up.  They 
therefore  inevitably  subject  the  author  of  them  to  criticism  and  ridi- 
cule. But,  apart  from  personal  considerations,  it  is  to  be  remembered 
that,  in  the  practice  of  both  medicine  and  surgery,  the  coexistence  of 
pregnancy  not  infrequently  modifies  materially  the  prognosis  and 
treatment.  Moreover,  it  is  one  of  the  most  grateful  functions  the 
physician  is  called  upon  to  perform  to  be  able  to  dissipate  unjust 
suspicions  of  pregnancy,  which  sometimes  cloud  the  reputations  of 
perfectly  pure  women.  On  the  other  hand,  the  writer  has  known 
many  cases  of  grievous  wrong  and  injustice  done  to  the  innocent  by 
a  careless,  hasty,  and  incorrect  decision  on  the  part  of  the  medical 
examiner.  The  so-called  signs  of  pregnancy"  are  based  upon  the 
physiological  changes  which  take  place  in  the  ovum,  and  the  changes 
wrought  by  the  growth  of  the  ovum  upon  the  maternal  organism. 
Many  of  the  signs,  therefore,  possess  little  w^eight,  and  serve  only  to 
draw  attention  to  the  possible  existence  of  pregnancy.  A  number  of 
the  signs  taken  together  furnish  cumulative  evidence  of  the  proba- 
bility of  pregnancy.  There  are,  however,  single  signs,  which,  taken 
individually,  make  pregnancy  probable  ;  only  a  few  possess  a  positive 
significance.  Hence  the  rule  that  the  physician  keep  ever  in  mind 
possible  sources  of  error,  and,  in  cases  of  doubt,  that  he  maintain  a 
prudent  reserve  in  the  expression  of  his  opinion. 

The  diagnosis  of  pregnancy  depends  upon  an  acquired  facility  in 
the  mental  grouping  of  symptoms  in  the  order  of  their  respective 
weight,  and  upon  a  familiarity  with  all  the  methods  by  which  objective 
symptoms  can  be  determined. 

We  have,  therefore,  to  consider  : 

1.  The  signs  of  pregnancy,  with  their  limitations  and  possible 
sources  of  error. 

2.  Methods  of  physical  exploration. 

3.  The  differential  diagnosis  of  pregnancy. 

The  Signs  of  Pregkakcy. 

The  suppression  of  the  menses  is,  to  most  women  who  have  been 
exposed  to  impregnation,  the  first  warning  of  the  occurrence  of  con- 
ception. Certainly,  where  they  have  been  previously  habitually  regu- 
lar, this  sign  rarely  leads  them  into  error.  Still  it  is  by  no  means 
reliable.  To  estimate  it  at  its  true  value,  it  is  necessary  to  bear  in 
mind  the  numerous  aberrations  to  which  the  menstrual  function  is 
subject.  In  married  women  a  retardation  of  the  menses  for  a  few 
days,  or  even  two  or  three  weeks,  is  not  an  uncommon  occurrence. 
These  retardations  are  not  unusual  in  newly-married  women,  in  whom 
the  disturbance  appears  to  follow  the  novelty  of  the  matrimonial  rela- 
tion. Again,  they  may  be  the  result  of  colds,  fatigue,  and  mental 
emotions.    In  the  unmarried,  who,  by  reason  of  imprudent  conduct, 


THE  DIAGNOSIS  OF  PREGNANCY. 


97 


have  had  occasion  to  fear  pregnancy,  a  retardation  sometimes  occurs 
as  the  result  of  pure  apprehension. 

The  causes  of  amenorrho^a  do  not  need  to  be  specified  here.  They 
are  operative  in  the  married  as  well  as  in  the  unmarried.  The  family 
physician,  however,  cognizant  of  the  peculiarities  and  temperaments 
of  his  patients,  will  easily  recognize  such  conditions,  and  separate 
them  from  the  cessation  of  the  menses  induced  by  pregnancy.  Should 
any  doubt  exist,  of  course  it  would  be  proper  to  suspend  judgment, 
and  await  the  advent  of  other  symptoms  before  expressing  an  opinion. 

Pregnancy,  while  it  suspends  ovulation,  the  usual  concomitant  of 
menstruation,  is  not  incompatible  with  a  periodic  flow,  which  may 
obscure  the  diagnosis.  When  conception  occurs  immediately  prior  to 
a  menstrual  period,  it  frequently  does  not  arrest  the  discharge,  though 
it  usually  diminishes  the  amount.  A  few  women  have  periodic  dis- 
charges during  the  first  two  or  three  months  of  pregnancy,  and,  in 
very  rare  cases,  throughout  its  entire  duration.  Authors  have  like- 
wise recorded  instances  of  women  whose  habit  it  was  to  menstruate  ( ?) 
only  during  pregnancy  (Montgomery).  In  all  such  cases  it  is  prob- 
able that  the  haemorrhage  is  of  cervical  origin.  In  one  instance  my 
friend  Dr.  L.  M.  Yale,  of  this  city,  verified  the  presence  in  the  cer- 
vical canal  of  a  small  muc(ms  polypus,  with  the  removal  of  which 
the  trouble  disappeared.  In  mentioning  these  deviations  from  the 
standard,  it  is  necessary  to  invite  the  student  to  view  them  in  proper 
perspective.  They  are  of  extremely  rare  occurrence,  and  the  physician 
will  not  often  fall  into  error  who  maintains  a  skeptical  attitude  toward 
cases  of  supposed  pregnancy  in  which  apparently  normal  menstruation 
is  reported  to  continue. 

In  women  who  are  habitually  irregular,  or  in  whom  the  menstrual 
periods  are  absent  altogether,  the  question  of  the  existence  of  preg- 
nancy is  often  in  the  early  months  a  very  puzzling  one.  There  are 
now  and  then  patients  who  menstruate  only  at  long  intervals.  If  they 
once  suspect  pregnancy,  they  are  apt  to  simulate  other  corroborative 
signs  ;  or,  on  the  other  hand,  they  may  proceed  far  in  gestation  with- 
out the  slightest  misgivings  of  their  true  condition.  In  such  instances 
the  physician,  unless  he  bases  his  opinion  on  purely  objective  symp- 
toms, is  at  times  drawn  into  error,  which  places  both  himself  and  his 
patient  in  a  ludicrous  position. 

In  the  same  category  are  to  be  placed  cases  of  pregnancy  occurring 
in  nursing  women  before  the  return  of  the  menses,  in  young  girls 
before  the  appearance  of  menstruation,  and  in  women  who  have  ap- 
parently passed  the  climacteric. 

Among  the  sympathetic  disturbances,  those  of  the  stomach  possess 
the  greatest  diagnostic  importance.  Nausea  and  vomiting,  occurring 
especially  in  the  morning,  and  following  suppression  of  the  menses,  are 
signs  to  which  the  women  themselves,  and  the  laity  in  general,  attach 

n 


98 


PHYSIOLOGY  OF  PREGNANCY. 


great  yalue.  Thej  are,  however,  sometimes  absent  in  pregnancy,  while 
they  are  present  in  a  variety  of  other  conditions.  They  are  notable 
features  of  chlorosis,  where  they  are  likewise  often  associated  with  sus- 
pension of  menstruation.  However,  after  eliminating  other  morbid 
causes,  they  are  always  suspicious  symptoms  in  women  who,  in  their 
sexual  relations,  have  exposed  themselves  to  conception,  and  who 
never  experienced  similar  sensations  in  the  unimpregnated  state. 
Abundant  salivation  possesses  a  similar  significance.* 

Tingling  sensations  and  swelling  of  the  breasts,  turgescence  and 
pigmentation  of  the  areola,  the  development  of  the  glandular  follicles 
around  the  nipple,  enlargement  of  the  superficial  veins,  and  the  secre- 
tion of  milk,  are  valuable  though  not  infallible  signs  of  pregnancy. 
Thus,  painful  sensations  and  sympathetic  swelling  of  the  breasts  may 
depend  upon  pathological  conditions  of  the  sexual  organs.  To  be  of 
importance,  they  should  be  persistent  and  progressive.  The  coloration 
may  be  the  relic  of  a  previous  pregnancy.  The  other  changes  in  the 
areola  rarely  lead  us  into  error  when  they  are  present,  but  I  have 
often  noted  their  entire  absence.  I  have  likewise  noted  cases  where 
there  was  entire  absence  of  milk  in  the  breasts  until  after  confinement. 
Numerous  and  very  curious  instances  of  milk  in  the  breasts  of  the 
non-pregnant  have  been  recorded.  The  importance  of  these  excep- 
tions is  greatly  lessened  by  the  fact  that  milk  rarely  appears  in  preg- 
nancy before  the  development  of  other  signs  which  enable  us  to  make 
the  diagnosis  certain. 

Increase  in  the  size  of  the  abdomen  during  the  child-bearing  period 
always  suggests  the  existence  of  pregnancy.  But  it  is  to  be  remem- 
bered that  it  is  not  invariably  of  uterine  origin.  Thus,  it  may  result 
from  ascites,  from  an  excessive  deposit  of  adipose  tissue  in  the  abdom- 
inal "walls,  from  tympanitic  distention,  and  from  various  abdominal 
tumors  having  no  connection  with  the  uterus.  If  the  enlargement 
proves  to  be  due  to  a  uterine  tumor,  we  have  then  to  exclude  fibroids 
in  the  earlier  months,  subinvolution,  and  the  increase  of  size  often 
associated  with  peri-uterine  inflammations.  The  absence  of  uterine 
enlargement,  in  women  supposed  to  be  several  months  pregnant,  pos- 
sesses, of  course,  absolute  value  in  the  way  of  purely  negative  testimony. 

The  changes  in  the  os  and  cervix  uteri  are  of  great  value  in  decid- 
ing the  question  of  pregnancy.  They  consist  of  softening  and  a3dema- 
tous  swelling  of  the  cervix,  velvety  character  of  the  mucous  mem- 
brane, associated  with  increased  cervical  secretion.  In  primiparae  the 
external  orifice,  instead  of  offering  the  sensation  of  a  transverse  slit, 

*  A  pellicle,  formed  upon  the  surfaco  of  the  urine,  twenty-four  to  forty-ei^lit  hours 
after  emission,  was  once  rej^arded  as  of  great  diagnostic  value.  It  received  the  name  of 
kiesteinc,  and  has  been  found  to  consist  of  a  proteine  substance,  triple  phosphates,  fungi, 
and  infusoria.  It  is  not  invariably  present  in  the  urine  of  pregnant  women.  It  may 
occur  at  other  times,  and  has  even  been  found  in  the  urine  of  the  male. 


THE  DIAGNOSIS  OF  PREGNANCY. 


99 


feels  circular.  In  mnltijoarae  the  tip  of  the  finger  penetrates  to  a 
greater  depth  than  in  its  former  state.  During  the  first  two  months 
the  changes  are  rarely  sufficiently  marked  to  distinguish  them  from 
conditions  that  obtain  at  or  near  the  menstrual  period. 

Quickening  is  the  term  used  to  designate  the  earliest  movements  of 
the  foetus  perceived  by  the  mother.  They  are  at  first  slight,  and  have 
been  compared  *^to  the  tremulous  motion  of  a  little  bird,  held  in  the 
hand  "  (Montgomery).  Modern  investigations  place  the  time  at  which 
the  foetus  first  begins  to  employ  its  muscles  at  about  the  tenth  week. 
It  is,  however,  somewhat  rare  for  these  movements  to  excite  the  at- 
tention of  the  mother  before  the  sixteenth  to  the  eighteenth  week, 
though  experienced  matrons  may  recognize  them  at  an  earlier  peri- 
od. Hyperaesthetic  women  do  so,  I  should  say,  as  a  rule.  The  clear 
statements  of  intelligent  women  leave  me  no  reason  to  doubt  that  they 
may  feel  life  as  early  as  the  twelfth  week.  At  first  the  sensation  is 
that  of  a  flutter  or  tap,  but  the  intensity  of  the  movements  is  increased 
as  pregnancy  advances.  They  are  rendered  more  active  by  a  long  fast, 
and  by  certain  positions  in  bed.  For  considerable  periods  during  the 
day  they  disappear  altogether.  Occasionally  they  may  be  suspended 
for  days  or  weeks  at  a  time,  without  the  life  of  the  child  having  be- 
come necessarily  compromised.  Cases  have  been  cited  in  w^hich  women 
have  never  recognized  the  feeling  of  quickening  throughout  the  entire 
period  of  pregnancy.  Dropsy  of  the  amnion  and  ascites  are  said  to 
obscure  the  sensation  of  the  fetal  movements. 

The  subjective  impressions  of  women  as  to  quickening  require, 
however,  to  be  received  with  reserve.  Instances  are  not  infrequent 
where  sterile  women,  misled  by  their  eager  longings  for  maternity, 
have  not  only  deceived  themselves,  but  have  succeeded  in  betraying 
their  medical  advisers  into  error  by  their  confident  assurances  of  hav- 
ing distinctly  felt  the  movements  of  the  child  in  the  womb. 

Fetal  movements,  on  the  otlier  hand,  when  recognized  by  the 
medical  expert,  furnish  conclusive  evidence  of  pregnancy.  These 
movements  may  be  active  or  passive.  Active  movements  may  be  de- 
tected by  the  eye,  or  by  immediate  contact.  They  seldom  assume 
much  distinctness  before  the  sixth  month,  though  this  is  not  in- 
variably the  rule.  (Thus,  a  patient  of  mine,  the  mother  of  six  chil- 
dren, aborted  at  the  fourth  month.  The  ovum  was  expelled  on  the 
27th  of  March.  She  gave  birth  on  the  25th  of  December  following, 
i.  e.,  just  nine  months  later,  to  a  full-term  child.  In  the  latter  part 
of  July  the  movements  were  clearly  appreciable  to  both  the  sight  and 
touch.)  At  first  the  sensation  is  that  of  a  simple  pat  or  throb,  but  in 
the  sixth  and  seventh  month  the  limbs  may  be  felt  to  escape  from 
under  the  hand  with  a  rolling  or  gliding  movement.  In  the  last  two 
months,  in  women  with  lax  abdominal  parietcs,  it  is  sometimes  pos- 
sible to  seize  with  the  fingers  a  limb  of  the  foetus,  especially  when  it 


100 


PHYSIOLOGY  OF  PREGNANCY. 


chances  to  form  a  projection  recognizable  through  the  intermediate 
coverings^  The  fetal  movements  have  been  closely  simulated  by  the 
irregular  and  spasmodic  action  of  certain  of  the  abdominal  muscles. 
In  the  celebrated  case  of  Joanna  Southcote,  who  at  the  age  of  sixty- 
four  claimed  to  be  with  child  by  the  Holy  Ghost,  Dr.  Eeece  says,  I 
felt  something  move  under  my  hand,  possessing  a  kind  of  undulatory 
motion,  and  appearing  and  disappearing  in  the  same  manner  as  a 
foetus."* 

Ballottement  is  the  term  applied  to  the  passive  movements  commu- 
nicated to  the  foetus  by  the  physician.  It  may  be  performed  either  by 
impressing  the  uterine  contents  with  the  two  hands,  laid  upon  the 
abdominal  wall,  so  as  to  cause  the  intervening  body  to  float  between 
them  ;  or  by  introducing  two  fingers  into  the  vagina  and  pushing  them 
suddenly  against  the  lower  segment  of  the  uterus  just  anterior  to  the 
cervix.  When  this  is  done,  the  head,  if  the  presenting  part,  is  made 
to  bound  away  from  the  fingers,  to  drop  down  again  in  a  few  moments 
upon  them  a  gentle  tap.  Vaginal  ballottement  can  sometimes 
be  practiced  successfully  as  early  as  the  latter  part  of  the  fourth  month. 
Ballottement  is  to  be  regarded  as  positive  proof  of  pregnancy,  as  there 
is  no  other  condition  in  which  a  solid  body  is  found  floating  in  the 
uterine  cavity. 

The  auscultatory  signs  consist  of  the  uterine  hruit  and  the  sounds 
of  the  fetal  heart.  The  discovery  of  the  latter  was  made  by  M.  Mayor, 
a  surgeon  of  Geneva,  as  appears  by  the  following  note  contributed  by 
the  editor  of  the  Bibliotheque  Universelle,"  in  speaking  of  the  compte 
rendu,  made  by  Percy,  June  29,  1818,  to  the  Academy  of  Sciences, 
upon  the  memoir  of  Laennec  relative  to  auscultation  :  "This  observa- 
tion reminds  us  of  one  made  by  M.  Mayor,  which  has  appeared  very 
interesting  to  us  in  its  connection  with  the  art  of  midwifery  and  legal 
medicine.  He  has  discovered  that  it  is  possible  to  recognize  with  cer- 
tainty whether  a  child  is  living  or  no,  by  apj^lying  the  ear  to  the  ab- 
domen of  the  mother  of  the  child  ;  if  the  child  is  living,  one  can  hear 
very  well  the  beatings  of  its  heart,  and  distinguish  them  from  those  of 
the  maternal  pulse."  f  Time  has  served  only  to  confirm  in  the  most 
complete  manner  the  accuracy  of  this  statement.  The  heart-sounds 
of  the  foetus,  when  once  clearly  heard,  are  now  regarded  as  the  most 
valuable  of  the  signs  of  pregnancy,  and  conclusive  evidence  that  the 
child  is  alive.  They  are,  like  those  of  the  mother,  distinctly  double, 
and  have  been  aptly  compared  by  Kergaradec  to  the  tic-tac  of  a  watch. 
They  are  much  more  rapid  than  the  corresponding  sounds  in  the  heart 
of  the  mother,  oscillating  between  120  and  160  per  minute.  They 
may  be  temporarily  increased  in  frequency  by  movements  of  the  mother, 
and  by  both  the  active  and  passive  movements  of  the  child.    At  the 

*  ^loNTGOMERY,  "Signs  of  Prepfnancy,"  second  edition,  p,  144. 
f  JouLiN,  "  Traite  complct  d'accouchement,"  1867,  p.  410. 


THE  DIAGNOSIS  OF  PREGNANCY. 


101 


beginning  of  a  pain,  especially  after  rupture  of  the  membrane,  the 
heart-sounds  often  become  more  frequent ;  on  the  other  hand,  they 
become  slowed  during  the  height  of  the  contraction,  and  may  even  for 
the  moment  cease  altogether,  either  in  consequence  of  the  compression 
of  the  child's  body,  or  as  the  result  of  the  disturbance  produced  in  the 
placental  circulation.  In  the  interval  between  the  pains,  the  average 
frequency  is  usually  restored.  If  at  any  time  the  frequency  of  the 
heart-beat  permanently  either  rises  above  or  falls  below  the  normal 
average,  the  child's  life  is  to  be  regarded  as  endangered.  As  the  fetal 
circulation  is  entirely  independent  of  that  of  the  mother,  there  is  no 
direct  relation  between  the  rapidity  of  the  pulsations  of  the  fetal  and 
maternal  hearts.  However,  in  the  febrile  affections  of  the  mother, 
the  health  of  the  child  may  become  coincidently  deranged,  with  re- 
sulting increase  in  the  frequency  of  its  heart's  sounds.  In  general,  the 
heart  beats  more  frequently  in  girls  than  in  boys,  a  circumstance  prob- 
ably owing  to  the  average  smaller  size  of  the  female  at  birth.  In 
fifty  observations,  Frankenhaeuser  *  found  the  average  in  the  boys  was 
124,  while  that  of  the  girls  was  144.  He  believed,  therefore,  that  it 
would  prove  possible  to  predict  the  sex  of  the  child  in  utero  three 
months  previous  to  confinement.  Subsequent  experience  has  demon- 
strated, however,  that  prophecies  based  upon  the  frequency  of  the 
heart-beats  are  at  best  of  only  approximative  value,  and  that  it  is  the 
part  of  wisdom  to  reserve  a  prognosis  which  may  be  falsified  by  time. 

The  fetal  heart  may  generally  be  made  out  by  the  eighteenth  to 
the  twentieth  week.  Under  favorable  circumstances  it  has  been  de- 
tected as  early  as  the  fifteenth  to  the  sixteenth  week.  It  is  usually 
heard  over  the  dorsum  of  the  foetus  ;  in  face-presentations,  on  the 
contrary,  it  is  heard  most  distinctly  over  the  anterior  surface  of  the 
thorax.  The  sound  is  often  obscured  by  the  thickness  of  the  abdomi- 
nal walls  in  fat  women,  and  by  an  excessive  amount  of  amniotic  fluid. 
When  the  dorsum  of  the  foetus  is  turned  posteriorly,  it  may  be  absent 
altogether.  It  is  customary,  therefore,  to  make  frequent  examinations 
at  intervals  before  deciding,  in  consequence  of  its  failure,  upon  the 
death  of  the  child. 

The  uterine  hruit  is  a  blowing  sound  synchronous  with  the  maternal 
pulse.  It  resembles  strongly  the  souffle  heard  in  aneurismal  tumors, 
and  varies  greatly  in  quality  und  intensity.  It  is  apt  to  be  louder  in 
markedly  anaemic  women.  During  uterine  contractions  it  possesses 
more  of  a  musical  character  ;  at  the  height  of  a  pain  it  may  disappear 
for  the  moment  altogether.  It  may  be  modified  by  the  pressure  of 
the  stethoscope  or  arrested  altogether.  When  first  discovered  by  Ker- 
garadec  (1822),  it  was  attributed  to  the  utero-placental  circulation,  and 
was  therefore  termed  the  placental  bruit.  As,  however,  it  was  found 
to  persist  two  or  three  days  after  delivery,  it  became  evident  that  the 

*  "Monatsschr.  f.  Geburtsk.,"  Bd.  xiv,  p.  161. 


102 


PHYSIOLOGY  OF  PREGNANCY. 


sound  must  be  of  uterine  origin.  It  is  now  the  generally  accepted  be- 
lief that  the  sound  is  produced  in  the  ascending  branches  of  the  arteria 
uterina.  Eotter*  and  Eapin  have  shown  that,  in  pressure  along  the 
course  of  the  artery,  both  when  made  through  the  abdominal  walls 
and  through  the  vagina,  a  vibratory  thrill  may  be  experienced  by  the 
touch,  which  corresponds  to  the  sounds  heard  in  auscultation. 

It  is  seldom  heard  before  the  fourth  month.  Spiegelberg  f  states 
that,  in  women  with  lax  abdominal  parietes,  he  has  succeeded,  by 
pressing  the  stethoscope,  placed  above  the  symphysis  pubis,  deep  down- 
ward so  as  to  reach  the  sides  of  the  lower  portion  of  the  uterus,  in 
detecting  the  murmur  as  early  as  the  eighth  to  the  ninth  week.  As  a 
sound  similar  to  the  uterine  bruit  may  sometimes  be  detected  in  uter- 
ine fibroids,  its  value  as  a  distinctive  sign  of  pregnancy  is  thereby 
greatly  impaired. 

A  hissing  sound  synchronous  with  those  of  the  fetal  heart  is  some- 
times heard  in  auscultating  the  abdomen.  This  sound  is  referable  to 
the  umbilical  cord,  and  is  termed  the  funic  souffle.  Its  etiology  is  a 
matter  of  conjecture.  As  it  is  only  found  in  fourteen  to  fifteen  per 
cent,  of  cases  examined,  it  possesses  moderate  value  as  a  sign  of  preg- 
nancy. 

Interrogation  of  the  Patient. — In  all  cases  of  presumed  pregnancy 
it  is  customary  to  commence  an  investigation  by  preliminary  inquiries 
as  to  the  existence  of  the  more  important  subjective  symptoms.  As 
such  are  to  be  regarded  the  suppression  of  the  menses,  the  so-called 
'^morning-sickness,"  salivation,  pricking  sensations  and  lancinating 
pains  in  the  breasts,  enlargement  of  the  abdomen,  and  quickening. 
As  we  have  already  seen,  however,  none  of  these  symptoms  are  really 
decisive.  Patients,  by  their  statements,  may  in  perfect  good  faith  lead 
the  physician  into  error  ;  or,  where  they  have  an  interest  in  practicing 
deception,  may  deny  the  existence  of  incriminating  symptoms  alto- 
gether. It  is,  therefore,  often  necessary  to  supplement  the  testimony 
of  patients  by  the  evidences  to  be  obtained  by  a  clinical  examination. 
Ordinarily  the  vaginal  touch  suffices.  In  a  few  cases  of  doubt  it  may 
be  necessary  to  possess  one's  self  of  all  the  objective  signs  before  arriv- 
ing at  a  conclusion. 

Methods  of  Physical  Exploratioi^". 

The  patient  may  be  examined  in  the  upright  or  recumbent  posi- 
tion. In  the  upright  position,  the  physician  may  first  examine  tlie 
breasts,  with  reference  to  the  existence  of  the  changes  characteristic 
of  pregnancy.  AVith  the  eye  he  takes  note  of  the  oedema  and  discolor- 
ation of  the  areola,  the  development  of  the  follicles,  the  secondary 
areola,  and  the  increased  size  of  the  organ.    To  distinguish  from  the 

*  Rotter,  "  Ueber  f uhlbares  Uteringcrausch,  "  Arch.  f.  Gynaek.,"  p.  539. 
f  "  Lehrbuch  dor  Gcb.,"  p.  104. 


THE  DIAGNOSIS  OF  TREGNAXCY. 


103 


enlargement  of  the  breast  due  to  adipose  tissue,  he  looks  for  the  pres- 
ence of  developed  veins  upon  its  surface,  and  with  the  touch  recog- 
nizes the  knotty,  uneven  feel  produced  by  the  development  of  the 
glandular  tissue.  By  pressing  the  breast  neai'  the  nipple  between  the 
thumb  and  index-finger  the  presence  of  milk  may  be  determined. 

An  examination  per  vaginam  is  sometimes  made  in  the  upright 
position,  in  cases  where  the  physician  desires  simply  to  rapidly  ac- 
quaint himself  with  the  condition  of  the  generative  passages  and  the 
lower  portion  of  the  uterus.  The  patient  either  stands  with  the  feet 
apart,  or  with  one  foot  raised  upon  a  stool,  while  the  physician,  kneel- 
ing before  her,  encircles  her  hips  with  the  left  arm,  and  with  the  right 
hand,  passed  beneath  the  clothing,  makes  the  requisite  exploration. 
This  method  furnishes  incomplete  results,  and  is  apt  to  offend  sensi- 
tive patients.  It  possesses  no  advantages  over  that  in  the  recumbent 
position,  and  is  rarely  resorted  to  except  in  the  hurry  of  office 
practice. 

Although  for  certain  purposes  it  may  prove  advantageous  to  choose 
the  lateral  or  knee-chest  position,  in  all  ordinary  cases  it  is  advisable 
to  examine  the  patient  upon  her  back,  as  being  most  convenient  for 
both  external,  internal,  and  conjoined  exploration. 

In  the  dorsal  position  the  body  should  be  as  nearly  horizontal  as 
possible,  with  the  head  and  shoulders  resting  upon  a  pillow,  and  the 
thighs  flexed  at  right  angles  to  the  body,  and  separated  from  one  another. 
In  this  way  the  greatest  possible  relaxation  of  the  abdominal  walls 
and  of  the  perinaeum  is  attained.  Corsets,  or  other  articles  of  apparel 
interfering  with  freedom  of  investigation,  should  be  removed.  The 
woman-  should  be  covered  with  a  sheet,  and  the  clothes  reflected  up- 
ward so  as  to  expose  the  abdomen.  Where  actual  inspection  is  not 
necessary,  it  is  well  to  draw  the  chemise  smoothly  over  the  abdominal 
walls  to  avoid  offending  the  modesty  of  the  patient.  When  it  is  of 
importance  to  survey  the  external  surface,  care  should  be  taken  to  so 
arrange  the  sheet  as  to  cover  the  pubic  region. 

Inspection  of  the  abdomen  enables  us  to  recognize  its  form  and 
shape,  the  coloration  of  its  surface,  the  striae  due  to  distention,  and 
the  condition  of  the  navel.  A  flattening  of  the  abdomen  at  the  um- 
bilical region,  with  bulging  at  the  sides,  would  lead  to  the  suspicion  of 
ascites.  A  depression  of  the  navel  is  incompatible  with  advanced 
pregnancy.  Fetal  movements  are  sometimes  visible  through  the  ab- 
dominal parietes. 

Palpation  of  the  abdomen  enables  us — 1.  To  recognize  the  size, 
shape,  and  consistency  of  the  uterine  tumor,  and  to  distinguish  it 
from  other  intra-abdominal  growths  ;  2.  To  ascertain,  in  advanced 
pregnancy,  the  presence  of  the  fcetus.  In  a  very  large  number  of 
cases  palpation  alone  seems  to  establish  the  existence  of  pregnancy. 
It  is,  however,  only  after  the  third  month  of  pregnancy,  when  the 


104 


PHYSIOLOGY  OF  PREGNANCY. 


fundus  uteri  can  be  felt  above  the  symphysis  pubis,  that  this  method 
of  exploration  becomes  available. 

In  its  performance  the  physician  stands  by  the  side  of  the  patient, 
and  with  the  tips  of  his  fingers  rapidly  traverses  the  abdomen  from 
the  pubes  upward.  In  this  way  he  takes  note  of  the  thickness  of  the 
abdominal  walls  and  of  the  general  position  of  the  uterus.  The  latter 
may  then  be  outlined  by  pressing  the  abdominal  walls  inward  to  the 
sides  of  the  uterus,  with  the  ulnar  borders  of  the  two  hands.  The 
uterus  is  then  steadied  with  one  hand,  while,  with  the  other,  intermit- 
tent pressure  is  made  to  determine  the  consistence  of  the  tumor.  In 
pregnancy,  after  the  second  month,  the  uterus  becomes  soft  and  elas- 
tic, a  condition  that  increases  with  the  growth  of  the  ovum,  so  that, 
toward  the  end,  palpation  often  furnishes  an  obscure  sense  of  fluctu- 
ation. The  physician  should  next  turn  his  face  toward  the  feet  of  his 
patient,  and  make  deep  pressure  above  the  symphysis  pubis  to  the 
lower  borders  of  the  uterus.  He  should  here  seek  to  discover  the  vi- 
bratory thrill,  which  may  sometimes  be  detected  along  the  course  of  the 
uterine  arteries.  At  the  same  time,  in  head-presentations  (after  the 
sixth  month),  a  hard,  round  body  can  generally  be  felt,  and  made  to 
float  to  and  fro  between  the  examining  fingers  of  the  two  hands.  In 
thin  persons,  with  relaxed  abdominal  and  uterine  parietes,  it  is  pos- 
sible, in  the  later  months,  to  trace  upward  the  back,  the  breech,  and 
the  extremities  of  the  foitus.  During  the  progress  of  the  examina- 
tion in  advanced  pregnancy,  the  movements  of  the  child  are  usually 
excited,  and  are  readily  appreciated. 

The  differential  diagnosis  between  pregnancy  and  other  sources  of 
abdominal  enlargement  is,  in  most  cases,  not  difficult.  In  subperi- 
toneal fibroids  of  the  uterus,  the  unevenness  of  the  surface  and  the 
hardness  of  the  tissues  are  distinctive.  But  it  must  be  remembered* 
that  fibroids,  though  they  commonly  cause  sterility,  do  not  actually 
exclude  pregnancy.  In  the  rare  cases  in  which  fibroids  and  pregnancy 
coexist,  the  diagnosis  for  a  time  may  be  doubtful.  In  one  such  in- 
stance which  I  have  recently  witnessed,  the  physician  twice  passed, 
with  entire  innocency  of  intention,  a  sound  to  the  fundus  of  the 
uterus.  The  woman  was,  at  the  time,  about  four  months  advanced 
in  gestation.  Two  months  later  she  gave  birth  to  a  premature  infant, 
which  lived  for  a  few  minutes  only. 

It  is,  therefore,  important,  where  any  uncertainty  exists,  to  await 
the  result  of  a  future  examination.  In  a  few  weeks'  time  the  rapid 
growth  of  the  pregnant  uterus  alone  suffices  to  establish  the  dis- 
tinction. 

Ovarian  cysts,  in  the  early  stages  of  their  growth,  occupy  a  posi- 
tion to  the  side  of  tlie  pelvis,  and  are  hardly  likely  to  be  confounded 
with  the  pregnant  uterus.  When,  however,  by  their  increase  in  size, 
they  fill  the  abdomen,  the  history  of  ovariotomy  shows  that,  without 


THE  DIAGNOSIS  OF  PREGNANCY. 


105 


a  full  and  complete  examination,  such  a  mistake  is  possible.  "Where 
ovarian  cysts  are  complicated  by  pregnancy,  the  latter  has  been  at 
times  oyerlooked,  simply  because  it  was  not  so  much  as  suspected. 
Thus,  a  young  servant-girl  was  sent  to  me  some  years  ago  to  consult 
me  relative  to  the  nature  of  an  abdominal  tumor.  The  diagnosis  of 
ovarian  cyst  was  readily  established.  A  year  later  she  sought  the  ad- 
vice of  a  surgeon,  formerly  of  this  city,  who  counseled  its  removal. 
Having  obtained  her  consent,  he  made  the  usual  incision  in  the  median 
line,  and  exposed,  to  his  horror,  the  pregnant  uterus.  He  afterward 
learned  that  the  girl,  having  been  assured  that  conception  was  impos- 
sible on  account  of  the  ovarian  disease,  had  yielded  to  the  solicitations 
of  her  lover.  Finding  herself  pregnant,  she  purposely  concealed  her 
condition,  and  had  sought  the  operation  when  seven  months  advanced, 
in  the  hope  that  a  fatal  issue  would  cover  her  shame.  The  ovarian 
tumor  was  left  untouched,  and  the  wound  was  quickly  closed.  The 
girl  died,  however,  a  few  days  afterward.  In  this  case,  the  undoubted 
presence  of  an  ovarian  cyst  and  the  reputable  character  of  the  girl 
combined  to  disarm  suspicion. 

In  ovarian  cysts  there  is,  on  palpation,  ordinarily  greater  distinct- 
ness of  fluctuation  than  in  the  gravid  uterus.  The  diagnosis  is, 
however,  mainly  based  upon  the  presence  or  absence  of  the  usual  signs 
of  pregnancy. 

Thick  layers  of  fat  in  the  abdominal  walls  and  ascites  could 
hardly  be  mistaken  for  pregnancy,  though  they  may  serve  to  obscure 
palpation. 

Tympanitic  distention  is  recognized,  in  part,  by  the  character  of 
the  percussion-note,  and,  in  part,  by  demonstrating  the  absence  of  tlie 
uterine  tumor.  The  latter  is  accomplished  by  directing  the  patient  to 
make  alternate  deep  inspirations  and  prolonged  expirations.  The  phy- 
sician then  places  the  left  hand  upon  the  abdomen.  During  the  long 
inspiration  he  remains  passive  ;  with  the  expiration,  he  presses  with 
the  fingers  of  the  right  hand,  placed  obliquely  against  those  of  the 
left,  in  the  direction  of  the  spinal  column.  With  the  recurrence  of 
inspiration,  he  holds  steadily  the  ground  previously  gained.  During 
the  following  expiration  further  progress  is  made,  and  thus  by  succes- 
sive advances,  in  case  no  intervening  body  prevents,  the  hand  is  made 
to  sink  inward  until  the  vertebras  are  felt.*  In  cases  of  undue  sensi- 
tiveness of  the  abdominal  walls,  chloroform  may  be  administered  to 
complete  anaesthesia.  Some  patients,  by  means  of  contractions  of  the 
abdominal  muscles,  succeed  in  producing  the  semblance  of  a  tumor, 
which  may  even  be  mapped  out  with  the  hands  applied  to  the  abdo- 
men. These  so-called  phantom  tumors"  occur  most  commonly  in 
hysterical  women  who  are  earnestly  desirous  of  becoming  mothers. 

*  This  valuable  method  is  borrowed  from  Professor  Spiegelberg's  "  Diagnose  der  Eier- 
stocktumoren,"  Volkmann's  "Samml.  klin.  Vortr.,"  No.  55. 


106 


PHYSIOLOGY  OF  PREGNANCY. 


They  are  eminently  calculated  to  entrap  the  unwary,  if  the  examina- 
tion be  confined  to  the  abdomen,  or  to  listening  to  the  patient's  sub- 
jective symptoms.  They  flatten  down  and  disappear  under  chloroform, 
or  when  the  attention  is  distracted  during  the  course  of  an  investiga- 
tion. 

Auscultation  furnishes  the  most  certain  evidences  of  the  existence 
of  pregnancy.  The  stethoscope  may  be  employed,  or  the  ear  may  be 
applied  directly  to  the  abdomen.  To  hear  the  fetal  heart  requires  a 
certain  amount  of  practice,  but  the  art  can  be  readily  acquired.  As 
the  sounds  are,  at  best,  of  feeble  intensity,  the  utmost  stillness  in  the 
neighborhood  of  the  patient  is  necessary  for  this  appreciation.  They 
are  always  heard  with  great  difficulty  before  the  end  of  the  sixth 
month.  There  is  no  special  point  at  which  they  can  be  invariably  dis- 
tinguished. In  head  or  breech  presentations,  with  the  back  of  the 
foetus  curved  and  in  contact  with  the  uterine  wall,  the  sounds  are  most 
clearly  to  be  made  out  over  its  dorsal  aspect.  In  face-presentations, 
on  the  contrary,  the  anterior  surface  of  the  child  is  i3ressed  against  the 
uterine  walls,  and  the  sounds  are  heard  with  the  greatest  distinctness 
over  the  chest.  As  in  the  last  three  months  of  pregnancy  the  cephalic 
presentations,  with  the  back  to  the  left,  preponderate,  the  heart-sounds 
are  oftenest  heard  in  a  line  extending  from  the  anterior  superior  spi- 
nous process  to  the  umbilicus.  AVhen  the  back  of  the  child  is  turned 
to  the  right,  it  is  likewise  directed  somewhat  posteriorly.  The  heart- 
sounds  are  then  less  accessible,  and  therefore  appear  feebler.  Care 
must  be  taken  not  to  confound  with  the  fetal  heart  the  conducted 
heart-sounds  of  the  mother,  or  the  aortic  pulse.  Thick  abdominal 
walls,  or  abundant  amniotic  fluid,  may  interfere  with  the  recognition 
of  the  heart-sounds.  When  the  back  of  the  child  is  turned  to  the 
rear,  or  during  a  uterine  contraction,  they  may  disappear  altogether. 
If  the  child  be  living,  however,  repeated  examinations  will  not  fail  to 
detect  them.  The  uterine  souffle  is  heard  with  maximum  intensity 
to  the  sides  of  the  uterus.  In  the  early  months  it  is  to  be  sought  for 
near  the  median  line,  just  over  the  symphysis  pubis. 

The  vaginal  touch  enables  one  to  effect  an  examination  of  the 
genital  canal  and  that  portion  of  the  uterus  which  is  contained  within 
the  pelvic  cavity.  The  accoucheur  should  accustom  himself  to  use 
either  hand  with  equal  ease,  and  to  conduct  an  examination  upon 
whichever  side  of  the  bed  his  patient  chances  to  be  lying.  The  index- 
finger  should  be  anointed  with  cold  cream,  lard,  butter,  vaseline,  oil, 
or  simple  soap-and- water,  to  make  its  introduction  into  the  vagina  less 
painful.  As  the  hand  is  passed  under  the  clothes,  it  is  a  good  plan 
to  cover  the  index  with  the  thumb  and  remaining  fingers,  to  prevent 
its  soiling  the  patient's  wearing-apparel.  The  patient  should  now 
be  told  to  separate  her  knees  widely,  while  the  index-finger  glides 
forward  over  the  pcrina3um  to  the  introitus  vagina3.    Note  should  be 


THE  DIAGNOSIS  OF  PREGNANCY. 


107 


taken  here  of  the  size  and  direction  of  the  orifice,  and  the  degree 
of  resistance  afforded  by  the  external  parts.  Where  there  is  much 
hair  about  the  pubes,  the  introduction  of  the  index-finger  into  the 
vagina  is  greatly  favored  by  separating  the  labia  with  the  fingers  of 
the  other  hand.  As  the  finger  enters  the  vagina,  it  is  well  to  notice 
the  urethra,  the  condition  of  the  rectum  (whether  filled  with  faeces), 
the  length  and  width  of  the  vagina,  and  the  amount  of  lubricating 
secretion  furnished  by  the  vaginal  walls.  To  explore  the  anterior  half 
of  the  pelvis,  close  the  unemployed  fingers  upon  the  palm  of  the 
hand,  direct  the  palmar  surface  of  the  index-finger  to  the  front,  and 
press  upward  to  the  presenting  part.  In  the  early  months,  place  the 
unemployed  hand  upon  the  abdomen  above  the  symphysis  pubis,  and, 
by  conjoined  manipulation,  make  out  the  size,  shape,  and  consistence 
of  the  uterus.  If  pregnancy  is  sufficiently  advanced,  ballottement 
may  be  produced.  To  reach  the  cervix,  the  finger  should  be  next 
turned  to  the  rear.  Many  practitioners  now  prefer  to  extend  the 
previously  closed  fingers,  and  press  them  opened  against  the  peri- 
nseum.  Should  the  cervix  not  be  readily  reached,  the  examination 
should  be  made  w^ith  both  the  index  and  middle  fingers.  If  the  mid- 
dle finger  is  introduced  slowly  and  with  care,  it  gives  no  additional 
pain,  and  increases  the  reach  by  nearly  an  inch.  The  actual  distance 
to  the  cervix  may  be  diminished  by  placing  the  closed  hand  under  the 
extremity  of  the  sacrum,  so  as  to  diminish  the  degree  of  pelvic  incli- 
nation. It  is  often  necessary  to  resort  to  this  measure  when,  toward 
the  end  of  pregnancy,  the  cervix  is  situated  unusually  high  up  and  is 
directed  well  to  the  rear.  With  the  touch,  we  recognize  the  size  and 
thickness  of  the  cervix,  the  length  of  both  the  anterior  and  posterior 
walls,  the  shape  of  the  os,  and,  if  open,  the  character  of  the  cervical 
canal. 

The  rectal  touch  is  only  necessary  where  there  is  obliteration  of  the 
vagina,  a  condition  which  does  not  exclude  pregnancy,  but  it  is  some- 
times usefully  resorted  to  in  other  cases  to  complete  information  ob- 
tained by  vaginal  exploration. 

The  speculum,  though  it  furnishes  us  with  a  view  of  the  coloration 
of  the  vagina,  a  most  valuable  sign,  is  rarely  employed  as  a  means  of 
diagnosis. 

Distinction  between  First  and  Subsequent  Pregnancies. 

In  women  who  have  once  completed  tlie  full  term  of  utero-gesta- 
tion,  the  imprints  left  by  the  pregnant  state  are  indelible,  and  easy  to 
recognize.  As  it  is  sometimes  a  matter  of  forensic  importance  for  a 
physician  to  be  able  to  distinguish  between  first  and  subsequent  preg- 
nancies, it  is  desirable  for  every  practitioner  to  make  himself  familiar 
with  the  characteristic  differences  between  the  two  conditions. 

In  primi2)ar(B  the  abdominal  integuments  are  firm  and  tense,  so 


108 


PHYSIOLOGY  OF  PREGNANCY. 


that  it  is  difficult  to  map  out  through  them  the  underlying  uterus, 
or  to  feel  the  head,  the  breech,  or  the  limbs  of  the  child.  The  striae 
found  upon  the  abdomen,  the  nates,  and  the  thighs,  appear  late  in 
pregnancy,  and  have  a  reddish-brown  or  slaty  color.  The  breasts  are 
full,  firm,  and  sensitive  to  pressure.  The  labia  are  in  apposition,  and 
the  fraenulum  is  intact.  The  hymen  is  torn,  but  each  fragment  re- 
mains attached  in  its  entirety  to  the  introitus  vaginae.  The  urethra 
is  hypertrophied,  and  appears  as  a  cylindrical  body,  of  a  reddish-blue 
color,  in  the  vaginal  orifice.  The  vagina  itself  is  narroAV,  with  dis- 
tinct transverse  ridges,  and  oftentimes  possesses  a  granular  feel,  from 
the  enlargement  of  the  papillte.  The  vaginal  portion  of  the  cervix 
is  soft.  When  the  head  enters  the  pelvis,  toward  the  end  of  preg- 
nancy, shortening  of  the  anterior  lip  takes  place.  The  os  externum 
is  closed,  or,  not  infrequently  toward  the  close  of  gestation,  admits 
the  passage  of  the  extremity  of  the  examining  finger.  It  then  feels 
like  a  round  opening,  with  smooth  borders,  and  a  sharp  inner  edge  at 
the  point  where  it  joins  the  cervical  mucous  membrane.  The  cervical 
canal  has  a  spindle  shape.  The  head,  in  the  latter  months,  as  a  rule, 
sinks  into  the  pelvis,  and  bulges  the  vagina. 

In  luomen  who  have  already  borne  children,  the  skin  of  the  abdo- 
men is  loose,  Avrinkled,  and  can  be  gathered  into  folds  by  the  hands. 
The  uterus  is  likewise  relaxed,  and  through  its  walls  can  be  felt,  in 
many  cases,  the  projecting  parts  of  the  foetus.  The  uterus  is  easily 
defined.  In  addition  to  the  striae  upon  the  abdomen,  noted  in  primi- 
parae,  many  of  older  date,  possessing  a  shining  white  or  silvery  ap- 
pearance, can  be  made  out.  The  breasts  are  flabby,  pendulous,  and 
marked  with  silvery  lines.  The  vulva  gapes  open,  and  wears  a  bluish 
aspect  from  the  development  of  the  superficial  veins.  The  frsenulum 
is  usually  found  to  have  been  lacerated.  The  carunculae  myrtiformes 
alone  remain  as  vestiges  of  the  hymen.*  The  vagina  is  smooth,  from 
the  obliteration  of  the  transverse  ridges.  Swelling  of  the  vaginal 
papillae  is  exceptional.  The  cervix  is  swollen,  and  has  a  cylindrical 
rather  than  a  conical  shape.  At  times  it  is  like  a  cone,  with  the  base 
downward.  The  os  is  open,  and  admits  the  extremity  of  the  finger. 
This  patulous  condition  is  due  to  lacerations  of  the  cervix,  which  are 
the  inseparable  concomitants  of  child-bearing.  The  lacerations  differ 
greatly  in  degree,  but  are  rarely  difficult  of  recognition.  As  they  are 
situated  usually  on  the  sides  of  the  cervix,  they  convert  the  os  into  a 
wide,  transverse  slit,  bounded  by  a  well-defined  anterior  and  posterior 
lip.  The  cervical  canal  has  a  funnel-shape,  narrowing  above.  In  the 
ninth  month  (in  some  cases  earlier)  the  finger  passes  readily  through 
the  OS  internum  to  the  child's  head.  The  latter  rarely  descends  into 
the  pelvis  before  the  advent  of  labor,  but  either  is  situated  at  the 
brim,  or  rests  upon  one  of  the  iliac  fossae. 

*  Vide  p.  7. 


THE  DIAGNOSIS  OF  PREGNANCY. 


109 


It  should  be  added,  finally,  by  way  of  caution,  that  while  the  pres- 
ence of  the  foregoing  signs  speaks  plainly  in  favor  of  the  existence  of  a 
previous  pregnancy,  their  absence  is  not  absolutely  incompatible  with 
the  occurrence  of  a  premature  labor,  or  even,  in  rare  cases,  with  the 
delivery  of  a  small  foetus  at  full  term. 

The  Diagi^osis  of  the  Death  of  the  Foetus. 

The  presence  of  a  dead  child  in  utero  may  be  inferred  where 
active  movements  are  not  elicited  by  palpation,  or  where  the  heart- 
sounds,  after  repeated  trials,  can  not  be  made  out.  As  we  have  seen, 
a  number  of  conditions  sometimes  combine  to  temporarily  render  it 
impossible,  even  when  the  child  is  living,  to  obtain  positive  results 
by  auscultation.  A  decision  should  not,  therefore,  be  based  upon  the 
results  of  an  isolated  examination. 

In  the  earlier  months,  previous  to  the  period  when  the  fetal  heart 
can  be  heard,  the  death  of  the  foetus  is  rendered  probable  by  flabbiness 
and  diminution  in  size  of  the  uterus,  by  a  flaccid  condition  of  the 
breasts,  and  certain  subjective  sensations  experienced  by  the  mother, 
such  as  languor,  chilliness,  bad  taste  in  the  mouth,  and  the  feeling 
of  a  weight  like  a  foreign  body  in  the  hypogastrium.  Certainty  is 
obtained  when,  through  the  ojoen  cervix,  the  cranial  bones  can  be 
made  out,  and  are  found  loose  and  movable  within  the  integuments. 

The  Duration"  of  Pregnajtct. 

There  is  no  question,  in  obstetrics,  upon  the  solution  of  which  so 
much  ingenuity  has  been  expended  as  the  determining  of  the  normal 
duration  of  pregnancy.  Inasmuch  as  it  has  proved  impossible  to 
ascertain  the  precise  moment  in  which  conception  (i.  e.,  the  fertilizing 
of  the  ovum  by  the  spermatozoa)  takes  place,  it  has  been  customary 
to  assume  as  the  starting-point  for  the  reckoning  of  gestation  either 
the  date  of  the  last  menstruation,  or  that  of  a  single  fruitful  coitus. 
It  would  seem  at  first  as  though  the  latter  would  lead  us  to  more 
nearly  accurate  results.  But,  aside  from  the  fact  that  the  distance 
of  time  between  insemination  and  conception  is  avowedly  variable,* 
it  is  only  in  rare  cases  that  the  particular  coitus  which  has  resulted 
in  pregnancy  can  be  definitely  ascertained.  Duncan  collected  46  cases 
in  which  connection  took  place  during  a  single  day  only,  and  found  the 
average  time  to  the  date  of  parturition  was  275  days.  Ahlfeld,  from 
an  analysis  of  425  cases,  obtained  an  average  of  271  days,  f    In  108 

*  Duncan,  "  Fecundity,  Fertility,  and  Sterility,"  second  edition,  pp.  433,  435. 

f  "  Beobachtungen  iiber  die  Dauer  der  Schwangerschaft,"  "  Monatsschr.  f .  Geburtsk.," 
Bd.  xxxiv,  p.  208.  Ahlfeld's  actual  reckoning  gave  an  average  of  269-91  days,  but 
this  was  afterward  corrected  by  Lowenhardt,  who  found  Ahlfeld's  tables  really  fur- 
nished an  average  of  2'70"94.  Vide  Lovtenhardt,  "Die  Berechnung  und  Dauer  der 
Schwangerschaft,"  "  Arch.  f.  Gynaek.,"  Bd.  iii,  p.  45S. 


110 


PHYSIOLOGY  OF  PREGNANCY. 


cases  furnished  by  Hecker  the  average  was  273 '52  days.*  Veit  pub- 
lished 43  cases,  with  an  average  of  276*42  days.f  In  63  cases  of  Faye's 
the  average  was  270 -66.  J;  Undoubtedly  many  of  the  cases  included  in 
these  tables  are  of  questionable  reliability ;  two  of  them,  indeed,  in 
which  confinement  is  reported  to  have  followed  coitus,  respectively 
in  329  and  330  days,  evidently  belong  to  the  realm  of  fable.  Assum- 
ing, however,  that  the  size  of  the  tables  serves  to  nearly  neutralize 
specific  inaccuracies,  the  small  value  of  the  averages  obtained,  as  a 
means  of  predicting  the  date  of  confinement,  is  shown  by  the  wide 
differences  between  the  terms  of  gestation  in  the  individual  cases  of 
which  the  tables  are  composed.  Thus,  in  Ahlfeld's  table  there  existed, 
between  the  longest  and  shortest  gestation,  a  difference  of  99  days  ;  in 
Hecker's,  a  difference  of  63  days ;  and  in  Veit's,  a  difference  of  36 
days.  In  the  breeding  of  domestic  animals,  in  which  conception,  as 
a  rule,  follows  a  single  act  of  sexual  congress,  similar  variations  are 
common.  In  the  now  familiar  observations  of  Tessier,  Krahmer,  and 
Spencer,  the  average  duration  of  gestation  in  rabbits  is  31  days,  the 
variation  8  days  ;  in  sheep,  pregnancy  averages  151  days,  and  the 
variation  amounts  to  26  days  ;  in  cows,  the  average  time  of  gestation 
is  283  days,  but  calving  may  occur  between  the  183d  and  the  356th 
day ;  in  mares,  the  average  time  is  347  days,  but  foaling  may  occur  be- 
tween the  287th  and  the  419th  day.# 

However,  Ahlfeld's  tables  show  that  the  bulk  of  confinements  vary 
within  narrow  limits.  Of  653  women,  in  15*93  per  cent,  delivery  oc- 
curred in  the  thirty-eighth  week;  in  27*56  percent.,  in  the  thirty- 
ninth  week  ;  in  26*19  per  cent.,  in  the  fortieth  week  ;  and  in  10*01 
per  cent.,  in  the  forty-first  week.  In  other  words,  more  than  half  the 
cases  occurred  in  the  thirty-ninth  and  fortieth  weeks,  and  80  per  cent, 
between  the  thirty-eighth  and  forty-first  week  inclusive.  Of  the  re- 
mainder, 14  per  cent,  took  place  prior  to  the  thirty-eighth  week,  and 
were  probably  influenced  by  the  many  operative  accidental  causes 
which  favor  prematurity.  Of  the  6  per  cent,  reported  as  occurring 
later  than  the  forty-first  week,  a  considerable  number  are  of  question- 
able authenticity.  Gestation  protracted  beyond  the  two  hundred  and 
eighty-fifth  day  is  certainly  of  very  rare  occurrence.  || 

*  Ahlfeld,  op.  cit,  p.  208. 
f  Ibid.,  p.  210. 

X  Other  tables  may  be  found  in  Montgomery,  "  Signs  of  Pregnancy,"  second  edition, 
pp.  493  etscq. 

*  Vide  Ahlfeld,  op.  cit ,  p.  216 ;  St.  Cyr,  "  Traite  d'obstetrique  veterinairc,"  pp.  107 
et  seq. 

II  Many  cases  of  apparent  protracted  gestation  find  their  explanation  in  the  fact  that 
conception  may  occur  just  prior  to  the  menstruation  period  succeeding  to  that  from  wiiieh 
the  count  is  made.  In  one  instance,  in  which  a  lady  was  confined  three  hundred  and  six 
days  after  the  last  menstrual  period,  the  statement  was  volunteered  that  for  twenty  days 
following  menstruation  "precautions"  against  pregnancy  had  been  resorted  to. 


THE  DIAGXOSIS  OF  PREGNANCY. 


Ill 


pREDICTIOisT  OF  THE  DAY  OF  CONFIKEMEN^T. 

In  all  schemes  for  predicting  the  date  of  confinement,  it  is  custom- 
ary to  throw  out,  as  defying  calculation,  the  exceptional  cases,  which 
fall  much  below  or  greatly  exceed  the  usual  average.  No  scheme  is 
ever  likely  to  be  devised  which  will  insure  accuracy  with  regard  to  the 
day  upon  which  labor  will  occur.  In  every  scheme  it  has  been  assumed 
that  errors  of  from  four  to  five  days  are  inevitable.  Moral  emotions, 
fatigue,  attacks  of  indigestion,  mechanical  causes,  and  the  like,  are 
recognized  as  liable,  toward  the  end  of  gestation,  to  precipitate  labor 
at  any  time.  But  a  vast  deal  of  ingenuity  has  been  expended  in  the 
endeavor  to  reduce  ordinary  errors  within  the  narrowest  limits. 

The  Last  Menstruation. — Now,  it  has  already  been  remarked  that  it 
is  only  in  rare  cases  that  the  day  of  conception  (i.  e. ,  insemination)  can 
be  utilized.  In  all  calculations  of  the  duration  of  pregnancy,  it  has 
been  customary,  therefore,  to  select  the  menstrual  period  as  the  start- 
ing-point. As  the  days  immediately  following  menstruation  are  those 
in  which  conception  usually  occurs,  the  end  of  menstruation  has  been 
adopted  by  some  as  the  most  suitable  point  of  departure.  Ahlfeld 
estimated  that  35 '55  per  cent,  of  married  women  conceived  on  the 
last  day  of  menstruation,  and  that  88*44  per  cent,  conceived  within 
twelve  days,  counting  from  the  first  of  menstruation.'*  Experience 
has  shown,  however,  that  there  is  no  single  day  in  the  intermen- 
strual period  in  which  conception  may  not  occur.  Jewish  women, 
indeed,  who  are  forbidden  sexual  intercourse  by  the  Mosaic  law  during 
menstruation  and  the  seven  days  following,  are  proverbially  fruitful. 
Lowenhardt  has  shown  that,  though  in  two  women  conception  follow 
in  each  a  single  act  of  coitus,  occurring  the  same  number  of  days  after 
menstruation,  there  is  no  necessary  correspondence  of  the  date  of  con- 
finement in  the  two.  f 

As,  therefore,  there  is  little  to  be  gained  by  estimating  the  day  of 
confinement  from  the  probable  day  of  conception,  it  has  become  the 
usual  rule  to  reckon  from  the  first  rather  than  from  the  last  day  of 
menstruation,  especially  as  most  women  exercise  more  care  in  preserv- 
ing the  record  of  the  former  date. 

From  the  days  of  Hippocrates,  it  has  been  customary  to  regard 
pregnancy  as  extending  over  ten  lunar  months,  or  ten  menstrual  pe- 
riods of  twenty-eight  days  each.  In  accordance  with  this  idea,  Nae- 
gele  I  proposed  a  ready  method  of  computing  two  hundred  and  eighty 
days  from  any  given  date,  which  has  since  his  time  been  generally 
adopted.  This  consisted  in  counting  forward  nine  months,  or,  what 
amounted  to  the  same  thing,  counting  backward  three  months,  and 
then  adding  seven  days  (in  leap-years,  after  February,  six)  to  the  date 

*  Ahlfeld,  op.  cif.,  p.  191.  f  Op.  cit.,  pp.  461  ci  seg. 

X  Naegele,  "Lchrbuch  der  Gcb.,"  achter  Auflage,  p.  122. 


112 


PHYSIOLOGY  OF  PREGNANCY. 


chosen  as  the  starting-point  of  the  calculation.  Naegele  selected  the 
first  day  of  the  last  menstruation.  His  method  is,  of  course,  equally 
ai3plicable,  when  the  day  of  cessation  is  preferred  as  the  point  of  de- 
parture. For  seven  months  in  the  year  Naegele's  method  is  absolutely 
correct.  In  February,  however,  four  days,  in  December  and  January, 
five  days,  and  in  April  and  September,  six  days  only  are  required  to 
complete  two  hundred  and  eighty  days.  Tables  may  be  found  in  most 
physicians'  visiting  lists,  by  means  of  which  the  two  hundred  and 
eighty  days  may  be  determined  at  a  glance.    The  following  circle  of 


Fig.  70. — Diagram  for  computing  pregnancy.  (Schultze.) 


Schultze  is  based  upon  Naegele's  method.  The  figures  between  the 
radii  show  the  exact  number  of  days  to  be  added  for  each  of  the 
months  severally.  The  figures  in  parentheses  are  to  be  employed  in 
leap-year. 

Unfortunately,  the  supposition  that  labor  comes  on  after  the  ex- 
piration of  ten  menstrual  periods  of  twenty-eight  days  each  is  correct 
for  only  a  small  number  of  cases,  so  that  it  has  been  found  necessary 
to  shift  the  ground  somewhat  to  the  position  that  the  normal  duration 
of  pregnancy  covers  ten  menstrual  periods.  The  instability  of  the 
reckoning  would  then  find  its  explanation  in  the  common  experience 
that  ten  consecutive  periods  of  exactly  twenty-eight  days  each  are  rare 
even  in  the  most  regular  of  women.  Although  ovulation  is  suspended 
during  pregnancy,  at  tlie  return  of  the  menstrual  epochs  the  existence 
of  an  ovarian  influence  upon  the  generative  organs  may  be  clearly 
traced  in  many  individuals.  At  such  times  a  sensation  of  fullness  is 
often  experienced  in  the  pelvic  organs,  associated  in  some  women  with 
an  awakening  of  the  sexual  appetite.    At  such  times,  too,  there  has 


THE  DIAGNOSIS  OF  PREGNANCY. 


113 


been  observed  a  tendency  to  miscarry,  so  that  it  becomes  incumbent 
upon  sensitive,  imi)ressionable  females,  predisposed  to  abort,  to  espe- 
cially avoid  either  reflex  or  mechanical  sources  of  disturbance  during 
the  continuance  of  the  state  under  notice.  When  the  ovum  reaches 
maturity,  the  recurrence  of  the  tenth  menstrual  epoch  furnishes  local 
conditions  in  a  peculiar  degree  favoring  the  production  of  labor. 
Lowenhardt  *  found  it  was  possible  to  calculate  the  duration  of  preg- 
nancy in  twenty-two  individuals  with  tolerable  accuracy,  by  assuming 
that  ten  menstrual  periods  represent  not  two  hundred  and  eighty  days, 
but  ten  times  the  length 
of  time  between  the 
last  menstrual  period 
and  the  one  immediate- 
ly preceding  it.  In  no 
case  thus  calculated  did 
the  error  exceed  five 
days,  a  degree  of  exact- 
itude unattainable  by 
the  method  of  Naegele. 

The  Date  of  Quick- 
ening.— When  the  date 
of  the  last  menstrua- 
tion can  not  be  obtained, 
it  is  customary  to  reck- 
on the  time  of  labor 
approximately  by  add- 
ing twenty-two  weeks  to 
the  date  of  quickening, 
which  is  assumed  to  oc- 
cur in  the  eighteenth 
week  of  pregnancy.  The 
extreme  variation,  how- 
ever, in  the  time  at 
which  quickening  oc- 
curs in  different  indi- 
viduals renders  this 
method  of  calculation  a 
very  uncertain  one. 

The  Size  of  the  Uterus.— As  the  increase  of  the  uterus  is  progres- 
sive, its  size  is  sometimes  used  in  determining  approximatively  the 
period  to  which  gestation  has  advanced.  According  to  a  rude  for- 
mula, commonly  employed  at  the  bedside,  the  uterus  is,  in  the  second 
month,  of  the  size  of  an  orange  ;  in  the  third  month,  of  the  size  of  a 

*  "  Die  Berechnung  und  die  Dauer  der  Schwangerschaft,"  "  Arch.  f.  Gynaek.,"  Bd. 
iii,  p.  470. 

8 


114 


PHYSIOLOGY  OF  PREGNANCY. 


child's  head  ;  in  the  fourth  month,  of  the  size  of  a  man's  head,  and 
can  be  felt  above  the  symphysis  pubis.  In  the  fifth  month,  the  fun- 
dus of  the  uterus  rises  to  a  point  midway  between  the  symphysis  and 
the  navel.  By  the  sixth  month,  it  reaches  the  level  of  the  navel.  In 
the  seventh  month,  it  should  be  the  breadth  of  two  to  three  fingers 
above  the  navel.  In  the  eighth  month,  it  rises  half-way  between  the 
navel  and  the  epigastrium.  In  the  ninth  month,  it  reaches  the  epigas- 
trium. In  the  tenth  month,  two  to  three  weeks  before  confinement, 
the  uterus  sinks  downward  and  somewhat  forward,  so  that  its  upper 
level  corresponds  very  nearly  to  that  of  the  uterus  in  the  eighth  month. 

In  the  foregoing  calculation  most  of  the  data  are  obtained  from  the 
relation  of  the  fundus  to  the  navel.  But  the  navel  is  not  a  fixed  point. 
Spiegelberg  found  the  distance  between  the  upper  border  of  the  sym- 
physis and  the  navel  varied  in  different  women  as  much  as  six  inches.* 
The  average  distance  from  the  symphysis  pubis  to  the  fundus  of  the 
uterus  in  the  different  months  of  pregnancy  he  found  was — 


From  the  22(1  to  the  26th  week   8^  inches.f 

"  "     28th  week   10^  " 

"  "     30th  week   11  " 

"        "  "     82(1  and  33d  week   11^  " 

"        "  "  34th  week   12  " 

"        "  "     35th  and  36th  week   12^  " 

"        "  "     37th  and  38th  week   13  " 

"        "  "     89tb  and  40th  week   13i  " 


But  the  size  of  the  uterus  is  subject  to  considerable  variations,  due 
to  the  size  of  the  child  and  the  amount  of  the  amniotic  fluid. 

*  "Lehrbuch  der  Geb.,"  Bd.  ii,  p.  115. 

•)•  These  measurements  exceed  considerably  those  furnished  by  Farre,  p.  83.  The  dis- 
crepancies are  due  in  part  to  the  extent  of  individual  variation,  and  in  part  to  the  fact 
that  they  were  made  with  a  tape-measure.  Thus,  Ahlfeld,  employing  the  cyrtometre  of 
Baudclocque,  found  the  distance  from  the  symphysis  pubis  to  the  fundus  only  ten  and  a 
half  inches  in  the  fortieth  week.  Ahlfeld  found  the  length  of  the  child  to  be  nearly 
double  the  distance  between  the  head  and  breech  when  the  child  assumed  the  attitude 
usual  in  the  uterus.  To  determine  the  date  of  pregnancy,  he  proposed  to  measure  the 
axis  of  the  foetus  in  utet'O,  by  means  of  a  cyrtometre,  one  extremity  of  which,  passed  into 
the  vagina,  rested  upon  the  child's  head,  while  the  other  was  extended  to  a  mark  upon  the 
abdominal  wall  corresponding  to  the  breech.  He  then  sought  to  establish  the  length  of 
a  child  at  each  week  of  pregnane}'.  His  tables  show,  however,  such  variations  in  the 
size  of  children  born  in  the  same  week  as  to  impair  the  practical  value  of  the  method. 
Vide  Ahlfeld,  "  Bestimmung  der  Grosse  und  des  Alters  der  Frucht  vor  der  Geburt," 
"  Arch.  f.  Gynaek.,"  Bd.  ii,  p.  353. 


TOE  PHYSIOLOGY  AND  MANAGEMENT  OF  CHILDBED. 


243 


or  the  tidying  of  the  room  by  household  Marthas,  often  becomes  the 
starting-point  of  nervous  restlessness,  which  is  with  difficulty  over- 
come by  the  aid  of  the  strongest  soporifics.  Should  the  mother  feel 
faint  and  exhausted,  she  should  be  allowed  a  cup  of  hot  tea  or  bouillon. 

In  multiparas  it  is  well  to  leave  with  the  nurse  some  form  of  ano- 
dyne, to  be  administered  in  ease  sleep  is  interrupted  by  the  frequent 
recurrence  and  severity  of  the  after-pains.  Opiates,  while  they  lull 
the  pain,  do  not,  after  labor,  arrest  those  physiological  changes  in 
the  uterus  with  which  the  after-pains  are  associated. 

Passing  Urine. — As  the  natural  impulse  to  urinate  after  delivery 
is  very  feeble,  even  when  the  bladder  is  full,  the  nurse  should  be  in- 
structed to  solicit  the  patient  to  pass  water  in  the  course  of  eight  or 
ten  hours.  The  act  of  urination  should  be  performed  upon  the  back, 
which  of  course  necessitates  the  use  of  the  bed-pan.  To  be  sure,  there 
are  a  good  many  women  who  are  able  to  pass  water  without  difficulty 
in  the  sitting  posture,  who  fail  in  the  attempt  when  recumbent.  Still, 
the  risk  of  exciting  haemorrhage  by  placing  the  patient  upright,  during 
the  first  four  or  five  days  after  delivery,  is  always  sufficient  to  control 
the  action  of  the  careful  physician.  The  physician  should  make  it  a 
rule  to  visit  his  patient  within  twelve  hours  from  the  time  of  confine- 
ment. He  should  then  inquire,  not  only  whether  she  has  passed 
water,  but  ascertain  the  quantity  voided.  If  the  quantity  has  not 
exceeded  three  to  four  ounces,  he  should  introduce  the  catheter  and 
make  sure  that  the  bladder  is  completely  emptied.  In  cases  of  reten- 
tion, the  urine  should  be  drawn  at  least  three  times  in  the  twenty-four 
hours.  Before  using  the  catheter,  the  external  parts  should  be  care- 
fully washed,  to  avoid  conveying  the  lochia  into  the  bladder,  as  the 
lochial  discharge  after  the  first  day  is  liable  to  excite  cystitis.  In 
introducing  the  catheter  beneath  the  bedclothes,  the  urethral  orifice 
can  readily  be  detected  by  first  feeling  for  the  tumefied  urethra  with 
the  index-finger  of  the  right  hand  through  the  anterior  vaginal  wall, 
and  then  following  it  in  a  forward  direction  until  the  meatus  is 
reached. 

Visits  of  the  Physician. — The  physician  should  see  his  patient  at 
least  once  daily  during  the  first  week  following  confinement.  During 
the  first  four  days  it  is  my  custom  to  make  both  a  morning  and  even- 
ing visit,  not  only  for  the  purpose  of  noting  carefully  the  pulse  and 
temperature,  but  to  be  sure  that  my  patient  is  not  made  a  victim  to 
the  traditional  prejudices  and  superstitions  of  the  monthly  nurse. 
If  the  physician  will  take  the  trouble  to  call  occasionally  upon  his 
patient  subsequent  to  the  first  week,  to  insure  the  unretarded  progress 
of  puerperal  convalescence,  he  will  do  much  to  circumscribe  the  field 
of  gynaecological  practice. 

General  Directions. — Great  pains  should  be  taken  to  keep  the  air 
of  the  lying-in  chamber  fresh  and  pure.    If  the  room  is  warm,  the 


244 


THE  PUERPERAL  STATE. 


patient  should  be  lightly  covered,  owing  to  the  tendency  during 
childbed  to  profuse  perspirations.  There  is  no  foundation  for  the 
prevalent  belief  that  it  is  dangerous  to  comb  the  hair  of  a  puerperal 
woman.  Nothing  contributes  so  much  to  the  removal  of  soreness, 
and  the  healing  of  wounds  in  the  genital  canal,  as  cleanliness.  Every 
morning  the  external  parts  should  be  washed  carefully,  and  at  least 
twice  daily  the  vagina  should  be  syringed  with  some  warm  disinfect- 
ant lotion.  My  own  favorites  are,  for  the  first  three  days,  an  infu- 
sion of  camomile  or  a  saturated  solution  of  boracic  acid.  After  the 
third  day,  when  decomposition  of  the  lochia  is  apparent  to  the  sense 
of  smell,  carbolic  acid  (  3  j  ad  Oj)  should  receive  the  preference. 

Diet. — The  diet  should  be  selected  with  reference  to  the  physio- 
logical requirements  of  the  patient.  Thus,  during  the  first  three  days, 
when,  as  a  rule,  the  patient  is  thirsty,  and  is  indifferent  to  solid  food, 
the  diet  should  consist  of  gruel,  milk,  milk-toast,  and  tea,  to  which 
may  be  added  clear  soups  and  bouillon  should  more  stimulating  ali- 
ments be  called  for.  It  is  equally  desirable  on  the  one  hand  to  avoid 
exciting  colics  and  catarrhal  affections  of  the  stomach  by  too  early 
resorting  to  a  substantial  regimen,  and  on  the  other  to  remember  that 
the  speedy  establishment  of  an  abundant  milk  secretion  is  apt  to  be 
hindered  by  subjecting  women  to  a  process  of  semi-starvation.  After 
the  bowels  have  moved  on  the  third  or  fourth  day,  the  normal  appetite 
usually  returns.  All  easily  digested  articles  of  food,  such  as  soft- 
boiled  eggs,  chicken-broth,  small  birds,  steak,  chops,  and  the  like, 
according  to  the  taste  of  the  patient,  should  then  be  allowed.  Cooked 
fruits  are  of  farvice  in  overcoming  the  natural  constipation  of  the 
puerperal  period.  The  popular  prejudice  against  fish  and  vegetables 
containing  a  large  amount  of  nitrogenized  substances  seems  to  me 
well  founded. 

Laxatives. — The  canonical  practice  of  administering  a  laxative  on 
the  third  day  is  of  unquestionable  utility.  Very  few  women  escape 
from  an  accumulation  of  fecal  matter  during  the  last  weeks  of  preg- 
nancy— an  accumulation  which  is  often  enormous  in  quantity,  and 
which  creates  a  predisposition  to  puerperal  affections.  The  remedies 
selected  should,  liowever,  be  adapted  to  the  peculiarities  of  the  indi- 
vidual. In  some  women  an  ordinary  injection  of  soap  and  olive-oil 
in  water  suffices  to  procure  an  adequate  evacuation  ;  in  others  the  ob- 
ject is  fulfilled  by  the  milder  laxatives,  such  as  the  compound  rhubarb 
pill,  a  claret-glass  of  Hunyadi-Janos  water,  or  the  compound  licorice 
powder  of  the  German  pharmacopoeia  ;  while  in  obstinate  cases  a  calo- 
mel purge,  or  some  such  combination  as  the  post-partum  pill  of  my 
friend  Professor  Barker,*  will  be  found  requisite.  Castor-oil  I  give  only 

*  Ext.  colocynth.  comp.,  ;  ext.  hyoscyami,  gr.  xv;  pulv.  aloes  soc.,  gr.  x;  ext.  nuc. 
vom.,  gr.  V  ;  podophyllin,  ipecacuanha,  au,  gr.  j.  M.  Ft.  pil.  (argent.)  No.  xii.  Of  these, 
two  usually  act  efficiently  and  without  causing  pain. 


THE  PHYSIOLOGY  AND  MANAGEMENT  OF  CHILDBED. 


245 


in  cases  of  severe  colic,  either  alone  or  combined  with  fifteen  drops  of 
laudanum.  In  haemorrhoids  complicating  puerperal  convalescence,  I 
can  add  my  testimony  to  that  already  given  by  Professor  Barker  as  to 
the  specific  curative  effect  of  half -grain  doses  of  aloes  administered 
night  and  morning. 

Nursing. — Every  healthy  woman  should  nurse  her  child  at  least 
through  the  puerperal  period.  The  advisability  of  continuing  lacta- 
tion subsequent  to  the  resumption  of  household  duties  must  depend 
upon  the  question  as  to  whether  the  mother  is  in  a  position  to  make 
the  necessary  sacrifices  to  the  interests  of  the  child.  When  the  do- 
mestic and  social  demands  upon  'her  time  and  thoughts  are  numer- 
ous and  pressing,  lactation  is  apt  to  be  imperfect,  and  the  child  will 
not  thrive.  Humanity,  in  such  cases,  requires  that  the  child  be  sur- 
rendered to  a  wet-nurse.  Nursing  may  be  rendered  impossible  by  a 
lack  of  milk,  by  flattened,  misshapen  nipples,  and  by  the  health  of 
the  mother.  It  should  be  prohibited  in  phthisis,  in  epilepsy,  and  in 
cases  of  syphilis  contracted  shortly  before  the  birth  of  the  child. 

The  child  should  be  applied  to  the  breast  after  the  mother  has 
rested,  and  within  the  first  twelve  hours  following  the  end  of  labor. 
Soon  after  birth  the  child  seizes  the  nipple  eagerly,  and,  though  the 
quantity  of  nourishment  obtained  is  small,  it  is  infinitely  better 
adapted  to  the  child's  needs  than  the  catnip-teas  and  sweet-oil  which 
monthly  nurses  employ  as  substitutes.  The  early  application  of  the 
child  to  the  breast  benefits  the  mother  by  promoting  the  contractions 
and  the  involution  of  the  uterus,  and  by  lessening  the  painful  disten- 
tion of  the  breasts  which  occurs  at  the  time  when  the  function  of  lac- 
tation is  fully  established. 

As  the  child  sleeps  for  the  most  part  during  the  first  few  days  of 
existence,  no  rule  can  be  laid  down  with  regard  to  the  frequency  with 
which  it  should  be  placed  to  the  breast.  Afterward  it  should  be  ac- 
customed to  some  regular  routine.  So  long  as  the  stomach  is  of  small 
capacity  and  regurgitates  a  portion  of  its  food,  the  interval  should  not 
exceed  a  couple  of  hours.  From  an  early  period,  however,  the  child 
should  be  accustomed  to  sleep  six  hours  at  night,  which  gives  an  op- 
portunity for  the  mother  to  recuperate  her  strength.  This  discipline 
is  of  course  not  practicable  where  the  child  sleeps  in  the  same  bed  with 
the  mother.  After  six  months  the  child  should  not  nurse  oftener 
than  five  or  six  times  in  the  twenty-four  hours. 

The  breasts  should  be  suckled  in  alternation.  The  nipples  should 
be  carefully  washed  both  before  and  after  nursing.  The  addition  of 
boracic  acid  to  the  water  prevents  the  development  of  fungi.  The 
extreme  sensitiveness  of  the  nipples  at  the  commencement  of  lactation 
can  be  greatly  relieved  by  applying  constantly  to  them  a  rag  wet 
with  the  liquor plumhi  suhacetat.,  in  the  proportion  of  a  teaspoonful  to 
a  tumbler  of  water.    For  a  few  days  a  metallic  shield  over  the  nipples, 


246 


THE  PUERPERAL  STATE. 


to  prevent  the  rubbing  of  the  night-dress  or  the  bedclothes,  is  a  source 
of  comfort. 

Duration  of  Lying-in  Period. — Most  women  expect  permission  to  be 
given  them  to  sit  up  upon  the  tenth  day.  There  should,  however,  be 
no  fixed  rule  about  leaving  the  bed  which  does  not  take  into  account 
the  individuality  of  the  sj^ecific  case.  Not  to  leave  the  bed  before  the 
tenth  day  is  a  safe  rule  in  normal  puerperal  convalescence  ;  but,  where 
there  are  wounds  to  heal  by  granulation,  a  much  longer  i^eriod  of  time 
may  be  necessary.  Garrigues*  expresses  his  conviction  that  "the  up- 
right and  sitting  j)ostures  ought  to  be  carefully  avoided  until  involution 
has  proceeded  so  far  that  the  uteruS  has  receded  from  the  anterior  wall 
of  the  abdomen  and  returned  to  the  pelvic  cavity" — a  rule  which 
would  allow  one  woman  to  sit  up  in  a  week,  while  another  would  be 
kept  in  bed  two  weeks,  or  even  longer.  The  continuance  of  the  lochia 
rubra  should  serve  as  a  warning  against  a  change  to  the  upright  posi- 
tion. The  first  ■  attempt  at  getting  up  should  be  tentative.  The  re- 
sumption of  household  duties  should  be  postponed  until  the  patient 
can  walk  about  without  fatigue  or  backache.  When  the  abdominal 
Vv'alls  are  greatly  relaxed,  a  well-fitted  bandage  should  be  worn  for 
weeks  subsequent  to  delivery. 

The  Care  of  the  New-born^  Ikfan^t. 

As  the  new-born  infant  possesses  feeble  powers  of  resistance  to 
cold,  the  first  bath  should  be  ninety-eight  degrees,  or  nearly  that  of 
the  body.  The  vernix  caseosa  should  be  softened  by  oil  or  fat-inunc- 
tion, and  gentleness  employed  in  its  removal.  The  child  should  then 
be  gently  dried  in  soft,  warm  cloths,  and  carefully  examined  with 
reference  to  any  possible  defect  of  formation  or  development.  The 
cjrd  should  be  wrapped  in  an  oiled  rag,  and  held  in  place  upon  the 
left  side  by  a  flannel  bandage.  After  the  cord  has  separated,  the 
wounded  surface  should  be  dressed  with  a  carbolic  salve  until  the  dis- 
charge ceases,  f  The  dressing  of  the  child  is  the  province  of  the  nurse, 
and  varies  considerably  in  the  different  social  ranks.  Cleanliness  and 
fresh  air  are  essential  to  healthy  development.  To  avoid  sprue,  the 
mouth  of  the  child  should  be  washed  with  cool  water  each  time  after 
nursing. 

Selecting  a  Wet-Nurse. — Should  the  mother  be  unable  to  nurse  her 
child,  a  wet-nurse  should  be  urgently  recommended.    In  selecting  the 

*  Garrigues,  "Rest  after  Delivery,"  "Am.  Jour,  of  Obstct.,"  October,  1880,  p.  861. 

f  Dr.  Goodell  seizes  the  cord,  after  it  has  been  cut  as  usual,  between  the  thumb  and 
forefinger  of  the  left  hnnd,  near  the  navel,  and  then  strips  off  the  gelatine  of  Wharton 
with  the  thumb  and  forefinger  of  the  right  hand.  The  pressure  at  the  navel  is  next 
temporarily  suspended  where  the  internal  portions  of  the  vessels  collapse.  The  cord  is 
thereupon  subjected  to  a  second  stripping,  tied  in  the  usual  manner,  and  left  free  without 
any  dressing  whatever.  The  result  is,  that  it  separates  without  any  bad  smell.  (  Vide 
Parry's  note,  Leishman'a  "Midwifery,"  third  American  edition,  p.  608.) 


THE  PHYSIOLOGY  AND  MANAGEMENT  OF  CHILDBED. 


247 


.latter,  an  examination  should  be  made  with  regard  to  her  constitution 
and  health.  The  physician  should,  by  inspecting  the  throat,  the  legs, 
the  glands  of  the  neck,  and,  if  possible,  the  genital  organs,  exclude 
the  existence  of  a  syphilitic  or  strumous  taint.  A  nurse  should  be 
between  twent}^  and  thirty-five  years  of  age,  and  should  present  all  the 
appearances  of  good  health.  The  gums  should  be  red  and  firm  ; 
the  breasts  should  preferably  possess  a  pyriform  shape,  and  should  be 
marbled  with  blue  yeins  ;  it  is  not  necessary  that  they  should  be  large, 
but  they  should  be  firm,  elastic,  and  nodular  from  abundance  of  glan- 
dular structure  ;  the  nipples  should  be  well  formed,  prominent,  and 
free  from  cracks  and  erosions  ;  the  milk  should  flow  easily,  and  not 
be  too  bluish  in  color.  The  age  of  the  milk  should  bear  some  corre- 
spondence to  that  of  the  child  to  be  suckled.  Aside  from  the  question 
of  adaptability,  it  is  obvious  that,  where  a  great  discrepancy  exists,  the 
milk  of  the  nurse  is  liable  to  fail  before /he  time  of  weaning  is  reached. 
One  of  the  best  tests  of  a  nurse's  capacity  is  the  appearance  of  her 
own  child.  If  the  latter  is  plump,  with  well-rounded  limbs,  and  with 
a  healthy  skin  and  mucous  membranes,  the  presumptions  are  in  her 
favor,  even  if  she  does  not  present  in  her  own  person,  as  Jacobi  sport- 
ively suggests,  "a  combination  of  Aphrodite,  Athene,  and  Psyche." 
When  a  choice  has  once  been  made,  a  change  should  not  be  recom- 
mended without  a  fair  trial.  It  is  by  no  means  uncommon  for  a  nurse 
but  recently  separated  from  her  child,  placed  among  strangers,  and 
introduced  to  a  foreign  mode  of  life,  to  temporarily  suffer  from  a  dimi- 
nution of  the  lacteal  secretion,  the  milk  returning  in  a  brief  period 
under  the  influence  of  kindness,  habit,  and  a  nourishing  regimen. 
Moderate  exercise  is  necessary  for  the  maintenance  of  health.  The 
nurse  should  be  allowed  to  drink  milk  freely,  but  malt  liquors  should 
be  prohibited,  at  least  until  toward  the  close  of  lactation. 

Artificial  Feeding. — If  it  is  impossible  to  procure  the  services  of  a 
wet-nurse,  or  if  the  aversion  of  the  parents  to  wet-nurses  as  a  class 
proves  unconquerable,  artificial  alimentation  must  be  tried .  It  is  un- 
questionable that  many  babies  thrive  fairly  when  brought  up  on  the 
bottle.  For  success,  scrupulous  cleanliness,  i^unctuality,  intelligence, 
and  experience  are  requisite.  The  beautiful  roundness  of  outline,  the 
Men  aise,  and  the  easy  dentition  of  infants  at  the  breast  are,  however, 
rarely  attainable  by  those  who  are  brought  up  by  hand.  Bottle-fed 
infants  are  apt  to  be  lean,  to  be  subject  to  attacks  of  indigestion,  and 
to  sulfer  from  nervous  disturbances  when  teething.  If  cow's  milk  is 
used  as  a  substitute  for  human  milk,  the  experiment  is  more  likely  to 
prove  a  success  in  the  country,  where  the  milk  can  be  obtained  fresh 
morning  and  evening,  than  in  the  city  where  milk  is,  of  necessity,  at 
least  twelve  hours  old  at  the  time  of  delivery,  and  thirty-six  hours 
old  before  a  fresh  supply  can  be  obtained.  My  own  experience  inclines 
me  to  favor  employing,  where  it  is  practicable,  milk  from  one  cow, 


248 


THE  PUERPERAL  STATE. 


especially  if  the  cow  is  selected  with  reference  to  the  child's  individu-^ 
ality,  precisely  in  the  same  manner  as  a  wet-nurse  wonld  be  selected. 
The  fitness  of  the  milk  to  the  child  is  to  be  determined  rather  by 
experiment  than  by  analysis.  In  a  general  way,  however,  it  is  well  to 
remember  that  the  milk  of  a  very  young  cow  is  deficient  in  fat -glob- 
ules, while  that  of  an  old  cow  is  apt  to  err  on  the  side  of  excessive 
richness,  and  that  either  extreme  is  equally  liable  to  tax  the  infantile 
organs  of  digestion. 

The  difference  in  the  digestibility  of  human  and  cow's  milk  is  de^Den- 
dent  upon  a  difference  in  the  molecular  arrangement  of  the  caseine  vari- 
eties they  respectively  contain.  The  acid  of  the  stomach  j)recipitates 
human  caseine  in  the  form  of  flocculent  shreds,  while  that  of  the  cow's 
milk  is  converted  into  firm,  solid  masses.  Now,  of  the  two  forms  it  has 
been  experimentally  proved  that  the  former  is  much  more  soluble  in  the 
gastric  juice  than  the  latter.  With  many  physicians  the  favorite  plan 
for  neutralizing  this  objection  consists  in  substituting  cream  for  milk 
(diluted  at  first  with  three  and  afterward  with  two  parts  water  [Bie- 
dert] ),  and  thus  to  reduce  the  quantity  of  caseine  to  minimum  pro- 
portions ;  but  this  diet,  by  confining  the  child  almost  entirely  to  the 
hydrocarbons,  to  the  exclusion  of  the  proteine  constituents,  has  never 
seemed  to  me  in  practice,  even  when  well  borne,  to  meet  the  full  tissue 
requirements  of  a  growing  child.  After  many  trials  of  this  mixture, 
which  found  a  warm  advocate  in  the  late  Professor  Childs,  of  this 
city,  I  have  finally  returned  to  milk  of  good  standard  quality,  stirring 
it  before  using  to  distribute  the  fat-globules  evenly  between  the  dif- 
ferent layers,  and  adding  to  it  water  proportioned  to  the  age  of  the 
child,  beginning  with  eight  tablespoonfuls  of  milk  to  eight  of  water, 
increasing  the  one  and  diminishing  the  other  a  tablespoonful  at  a 
time  as  rapidly  as  the  digestive  organs  exhibit  a  toleration  of  the 
change.  The  water  does  not,  of  course,  alter  the  chemical  constitution 
of  the  caseine,  but  aids  digestion  by  provoking  an  increased  flow  of  the 
gastric  juice,  and  incidentally  contributes  to  alleviate  thirst  (Jacobi). 

City  milk  should  be  boiled  to  prevent  fermentation,  an  unnecessary 
practice  when  milk  can  be  obtained  fresh  night  and  morning.  Instead 
of  plain  water,  Jacobi  has  pointed  out  the  utility  of  using  some  sub- 
stance which  by  its  physical  consistence  is  able  to  hold  the  caseine- 
clots  in  suspension,  thus  protecting  the  stomach  from  irritation,  while 
they  are  being  prepared  for  dissolution."  I  have  been  in  the  habit  of 
following  out  to  this  end  his  earlier  suggestion  to  employ  an  indif- 
ferent substance,  as  gum-arabic  or  isinglass  for  very  young  children, 
and  afterward  a  thin  decoction  of  oatmeal  or  barley,  according  to  the 
tendency  of  the  child  to  constipation  or  diarrhoea. 

Condensed  milk  is  popular  with  many  physicians,  because  children 
with  whom  it  agrees  fatten  upon  it,  and  suffer  but  little  from  indiges- 
tion and  loose  passages.    The  large  amount  of  sugar  it  contains  un- 


ACCIDENTAL  COMPLICATIONS.— ABNORMALITIES  OF  THE  UTERUS.  249 


fits  it.  however,  for  prolonged  use.  I  have  seen  a  number  of  children, 
exclusively  fed  upon  it,  after  passing  through  apparently  a  blooming 
infancy,  develop  symptoms  of  rickets  at  the  end  of  their  first  year. 
I  have,  however,  been  in  the  habit  of  allowing  its  habitual  use  during 
the  first  three  months  of  existence,  and  in  the  city  during  the  hot 
months  of  summer. 

Whatever  the  preparation  selected,  it  should  be  warmed,  before  it 
is  given  to  the  child,  to  blood-heat.  A  small  quantity  of  salt,  and  a 
grain  or  two  of  bicarbonate  of  soda,  or  a  tablespoonful  of  lime-water, 
should  be  added  to  the  infant's  food,  the  former  to  promote  assimila- 
tion, and  the  latter  to  neutralize  any  free  acid  the  milk  may  chance  to 
contain.  When  artificially  reared,  many  children  do  not  gain  flesh, 
in  spite  of  apparently  healthy  digestion.  I  have  often  derived  great 
benefit  after  the  third  month  from  the  addition  to  each  bottle  of  a 
tablespoonful  of  Lofflund's  Liebig's  food  for  infants.  Presumably  the 
various  forms  of  malt  extract  now  so  popular  in  this  country  would 
serve  the  same  purpose  equally  well. 

The  bottle  from  which  the  child  is  fed  should  be  scalded  each  time 
that  it  is  used,  and  should  then  be  filled  with  cold  water  to  which  a 
little  soda  has  been  added.  The  tube  and  mouth-piece  should  both 
be  washed,  cleaned  with  a  brush,  and  allowed  to  soak  in  cold  water, 
in  the  intervals  of  feeding.  Unless  every  precaution  is  taken  to  prevent 
the  development  of  fungi,  a  bottle-fed  infant  will  never  prosper. 


THE  PATHOLOGY  OF  PEEGI^AlSrCY. 


CHAPTER  XIV. 

ACCIDENTAL  COMPLICATIONS.— ABNOTtMALlTIES  OF  THE  UTERUS. 

Variola. — Rubeola. — Scarlatina. — Scarlatina  puerperalis. — Cholera. — Typhus,  typhoid,  and 
relapsing  fever. — Malarial  fever. — Icterus. — Cardiac  diseases. — Pneumonia, — Emphy- 
sema, chronic  pleurisy,  and  empyema. — Phthisis. — Syphilis. — Chorea. — Surgical  oper-' 
ations  during  pregnancy. — Double  uterus. — Antcversion  and  anteflexion. — Retrover- 
sion.— Retroflexion. — Prolapse  of  uterus  and  vagina. — Hernias. 

The  pathology  of  pregnancy  includes  the  various  morbid  condi- 
tions which  exercise  an  unfavorable  influence  upon  pregnancy,  whether 
of  maternal  or  fetal  origin. 

The  maternal  diseases  comprehended  under  this  title  may  consist 
of  simple  exaggerations  of  normal  disturbances,  a  class  which  has, 
however,  already  received  attention  m  connection  with  the  chapter  on 


250 


THE  PATHOLOGY  OF  PREGNANCY. 


the  management  of  pregnancy  ;  accidental  complications  which  mate- 
rially influence  the  circulation  or  the  integrity  of  the  pelvic  organs  ; 
and,  finally,  diseases  of  the  uterus  and  the  uterine  appendages  which 
endanger  the  health  of  the  ovum,  or  pave  the  way  to  its  expulsion. 

The  pathological  processes  which  atfect  the  ovum  may  be  primary, 
or  may  result  secondarily  from  maternal  disturbances. 

The  haemorrhages  of  the  first  half  of  pregnancy  and  the  prema- 
ture expulsion  of  the  ovum  are  ordinarily  the  result  of  fetal  or  mater- 
nal disease.  Their  consideration,  therefore,  forms  a  fitting  conclusion 
to  the  subject-matter  in  hand. 

The  management  of  the  haemorrhages  occurring  in  the  second  half 
of  pregnancy  requires  a  preliminary  knowledge  of  the  operative  pro- 
cedures of  midwifery.  Its  consideration  will  therefore  be  postponed 
until  the  principles  governing  the  conduct  of  difficult  labor  have  un- 
dergone discussion. 

Morbid  states  which  exercise  an  unfavorable  influence  less  during 
pregnancy  than  after  the  development  of  labor  will,  to  avoid  double 
mention,  be  considered  in  connection  with  the  pathology  of  the  latter 
process. 

Accidental  Complications  of  Pkegnancy. 

Variola  attacks  pregnant  women  more  frequently  than  any 
other  eruptive  fever,  and,  although  it  manifests  a  preference  for  those 
in  whom  pregnancy  is  not  far  advanced,  its  type  is  severer  and  its 
prognosis  graver  when  it  affects  women  near  their  confinement. 

Variola  is,  unless  of  a  mild  form,  a  peculiarly  dangerous  complica- 
tion of  pregnancy,  greatly  imperiling  the  life  of  both  mother  and 
foetus,*  through  its  tendency  to  metrorrhagia  and  abortion. 

When  the  disease  pursues  its  course  without  producing  abortion,  the 
child  may  present  characteristic  variolous  cicatrices,  or  the  latter  may 
be  absent.  Occasionally  the  child  remains  unaffected  by  the  disease 
until  after  birth,  and  may,  sometimes,  escape  it  altogether.  During 
epidemics  of  variola,  women  may,  without  manifesting  other  symptoms 
of  infection  from  the  variolous  poison,  give  birth  to  premature  chil- 
dren, who  remain  unaffected  with  the  disease.  Children  sometimes 
suffer  from  variola  either  before  or  soon  after  birth,  while  their  mothers 
enjoy  complete  immunity  from  the  disease,  f 

The  healthy  child  of  a  mother  affected  with  variola,  or  of  one  vac- 
cinated during  pregnancy,  may  be  insusceptible  to  vaccinia  for  some 
time  after  birth. J; 

*  Meyer,  "  Uebcr  Poeken,  bcim  wcibliclien  Geschlecht,"  Berlin.  "  Bcitr.  z.  Geburtsh.," 
ii,  1873,  p.  197. 

f  SciiROEDER,  "  Lehrbucli  d.  Geburtsh.,"  p.  864. 

X  SriEGELRERG,  "  Geburtsli.,"  p.  259 ;  Max  Runge,  "  Die  acute  Infectionskrankheiten  in 
atiologisehe  Beziehung  zur  Schwangcrschaftsunterbrochung,"  Volkmann's  "  Samml.  klin. 
Vortr.,"  No.  174,  p.  1376. 


ACCIDENTAL  COMPLICATIONS.— ABNORMALITIES  OF  THE  UTERUS.  251 


It  is  advisable  that  all  women,  becoming  pregnant  during  an  epi- 
demic of  variola,  should  be  immediately  vaccinated. 

Rubeola  is  an  infrequent  complication  of  pregnancy,  but  is  serious 
on  account  of  its  tendency  to  become  haemorrhagic  and  to  produce 
metrorrhagia,  fatal  alike  to  mother  and  child.  Pneumonitis  is  a  very 
frequent  and  dangerous  complication  of  puerperal  rubeola. 

Scarlatina  is  a  less  frequent  complication  of  pregnancy  than  vari- 
ola, attacks  primiparae  by  preference,  although  not  exclusively,  and 
manifests  a  decided  tendency  to  develop  itself  in  the  puerperal  state, 
even  when  infection  has  taken  place  in  the  earlier  months  of  preg- 
nancy. Olshausen  *  was  able  to  collect  from  all  the  medical  literature 
at  his  disposal  only  seven  cases  of  scarlatina  occurring  during  preg- 
nancy, while  the  number  of  cases  taking  place  in  the  puerperal  state 
amounted  to  one  hundred  and  thirty-four. 

In  the  majority  of  recorded  cases  infection  is  known  to  have  been 
only  possible  at  a  time  more  or  less  remote  from  the  confinement,  and 
the  tardy  development  of  the  disease  is,  therefore,  most  rationally 
referred  to  a  prolonged  period  of  incubation,  extending  in  some  in- 
stances over  weeks  or  months. 

Assuming  the  correctness  of  this  theory,  we  must  infer  that  some 
unknown  condition  unfavorable  to  the  development  of  the  scarlatinous 
poison  exists  during  pregnancy  and  is  removed  by  parturition. 

The  mortality  of  scarlatina,  occurring  in  pregnancy  and  in  the 
puerperal  state,  varies  notably  in  different  epidemics,  although  it  is 
usually  high,  t  Attacks  occurring  immediately  after  confinement  are 
more  fatal  than  those  developed  later. 

The  stage  of  invasion  may  be  entirely  absent  or  may  exist  for  one 
or  two  days  before  the  appearance  of  the  eruption.  When  present,  it 
is  characterized  by  intense  febrile  movement,  emesis,  and  notable  con- 
gestion of  the^  face.  Usually,  however,  the  earliest  announcement  of 
the  attack  consists  in  the  sudden  development  of  the  eruption  on  all 
parts  of  the  body.  The  eruption  soon  assumes  a  characteristic  livid 
color,  which  is  usually  retained  until  the  fatal  issue,  should  the  latter 
occur  within  a  week. 

The  pharyngitis  and  tonsillitis  are  either  very  mild  or  entirely  ab- 
sent. Diarrhoea  is  a  frequent  and  dangerous  complication.  Aside 
from  the  above-mentioned  peculiarities,  puerperal  scarlatina  presents 
no  important  variations  from  the  clinical  history  of  ordinary  scarlet 
fever.  The  lochial  discharge,  the  lacteal  secretion,  and  the  uterine 
involution  are  unaffected  by  the  disease. 

*  Olshausen,  "  Untersuch.  iib.  d.  Complic.  des  Puerp,  m.  Scarlat.  u.  d.  sogenannte  S. 
puerperalis,"  "  Arch.  f.  Gynaek.,"  ix,  1876,  p.  169;  Braxton  Hicks,  "  Trans,  of  the  Obstet. 
Soc.  of  London,"  vol.  xvii. 

\  Denham  saw  only  one  recovery  in  eight  and  Hicks  only  four  recoveries  in  eighteen 
cases,  while  McClintock  had  but  ten  fatal  results  in  thirty-four  cases. 


252 


THE  PATHOLOGY  OF  PREGNANCY. 


Antipyretic  measures,  particularly  cool  baths,  are  indicated  in  pro- 
portion to  the  intensity  of  the  febrile  movement.  Cathartics  are  to 
be  avoided,  because  of  the  inherent  tendency  to  diarrhoea,  alluded  to 
above.  Stimulants  are  to  be  fearlessly  employed  when  asthenic  symp- 
toms are  developed. 

Scarlatina  Puerperalis. — Some  authors  have  applied  the  designation 
scarlatina  puerperalis  "  to  an  infectious  disease  which,  although  re- 
sembling scarlatina,  is  still  said  to  be  identical  with  or  closely  related 
to  puerperal  fever.  The  theory  advocated  by  them  is  based  upon  the 
fact  that,  in  the  cases  upon  which  their  deductions  are  founded,  the 
angina  was  trivial  in  character ;  the  attacks  occurred,  usually,  within 
three  days  after  confinement ;  infection  with  scarlatinous  poison  could 
not,  in  the  majority  of  cases,  be  established  ;  the  rate  of  mortality  was 
very  high,  and  peritonitis  and  cellulitis  were  often  revealed  on  autopsy. 
Olshausen  *  concludes  with  apparent  justice,  after  a  careful  review  of 
the  reasons  for  and  against  the  introduction  of  this  new  disease  into 
obstetric  nosology,  that  the  grounds  for  its  establishment  are  insuffi- 
cient, and  that  the  cases  of  so-called  ^'  scarlatina  puerperalis  "  are  noth- 
ing more  than  ordinary  cases  of  scarlet  fever,  modified  by  the  concomi- 
tant puerperal  condition,  but  in  no  way  akin  to  puerperal  pyaemia 
or  septicaemia.  It  is  worthy  of  note  that  scarlatina  and  puerperal 
fever  may,  in  rare  instances,  occur  in  combination  without  mutually 
affecting  their  respective  signs  and  symptoms.  Braxton  Hicks  f  advo- 
cates the  extreme  theory  that  a  puerperal  woman,  when  infected  with 
scarlatina,  develops  puerperal  fever,  and  that  persons  other  than  lying- 
in  women,  contracting  the  disease  through  intercourse  with  the  puer- 
peral patients,  are  attacked  by  scarlatina  of  the  usual  form. 

Cholera. — The  predisposition,  on  the  part  of  pregnant  and  puer- 
peral women,  to  cholera  Asiatica  is  not  usually  decided,  but  varies 
with  different  epidemics,  and  is  more  marked  in  cities  than  in  the 
country.  Women  are  most  liable  to  an  attack  of  cholera  in  the  latter 
half  of  pregnancy,  particularly  in  the  seventh  and  eighth  months,  and 
the  prognosis  is  gravest  for  cases  occurring  at  those  periods.  The 
prognosis  is  almost  necessarily  fatal  in  the  case  of  children  born  before 
the  ninth  month.  J;  The  intensity  of  the  disease  is  somewhat  mitigated 
by  the  existence  of  the  puerperal  state.  Slight  attacks  of  cholera  may 
take  their  natural  course  without  prejudicial  effects  uj^on  mother  or 
foetus,  but  the  disease  frequently  results  in  abortion  or  premature 
delivery,  due,  in  part,  to  haemorrhagic  metritis.  The  pathological 
uterine  conditions  observed  in  the  cases  recorded  by  Slavjansky  *  com- 

*  R.  Olshauskn,  loc.  cit. 

f  Braxton  Hicks,  "  Trans,  of  the  Obstet.  Soc.  of  London,"  1871,  pp.  44,  75. 
}  Ueb.  d.  Einfluss  d.  C.  auf  Schw.  u.  Wochenbett,"  "Monatsschr.  f.  Gebtirtsh.,"  18G8, 
xxxii,  p.  60. 

*  Slavjansky,  *'  Endontctrit.  decidualis  hiem,  bci  Cholerakrankcn,"  "  Arch,  f .  Gynaek.," 
iv,  1872,  p.  293. 


ACCIDEXTAL  COMPLICATIOXS.— ABNORMALITIES  OF  THE  UTERUS.  253 


prised  roughening  of  the  inner  surface  of  the  uterus  by  dark-violet 
shreds  of  the  decidua  vera,  numerous  extravasations  permeating  the 
mucous  membrane,  which  remained  intact  in  some  places  and  was 
ulcerated  at  others,  besides  the  presence  in  the  uterine  cavity  of  coagu- 
lated blood,  pus,  and  shreds  of  the  uterine  mucous  mernbrane. 

The  placenta  foetalis  presented  granular  degeneration  and  almost 
complete  disintegration  of  the  epithelium  covering  the  villi.  Both 
pathological  processes  above  described  conspire  to  induce  the  death  of 
the  foetus,  which  then,  in  common  with  coagula  and  inflammatory 
products  in  the  uterine  cavity,  acts  as  a  foreign  body  and  produces 
abortion.  Schroeder  *  refers  the  death  of  the  foetus  to  asphyxia  pro- 
duced by  changes  in  the  maternal  blood  which  interfere  with  the  pla- 
cental respiratory  function.  The  clinical  history  of  cholera  is  not 
materially  affected  by  coexisting  pregnancy,  except  in  so  far  as  uterine 
symptoms  are  concerned.  Eclampsia  sometimes  occurs,  and  irregular 
uterine  pains  may  persist  for  several  days  without  producing  abortion,  f 
Cholera  does  not  specially  predispose  to  puerperal  diseases,  nor  does 
it  afford  protection  against  them.  Lactation,  whether  commencing  or 
already  established,  is  not  markedly  affected  by  cholera,  although  the 
lochia  are  often  almost  suppressed. 

The  treatment  is  conducted  upon  general  principles.  The  artifi- 
cial induction  of  premature  delivery  has  had  many  advocates  on  ac- 
count of  its  supposed  tendency  to  ameliorate  the  prognosis,  but  has 
.now  fallen  into  disrepute,  although  judicious  measures  to  hasten  par- 
turition, already  begun  by  Nature,  are  regarded  as  justifiable. 

Typhus,  Typhoid,  and  Relapsing  Fevers. — These  fevers  more  fre- 
quently complicate  the  earlier  than  the  later  months  of  pregnancy, 
and  affect  the  prognosis  more  seriously  at  the  former  epoch,  owing 
to  the  greater  tendency  then  existing  to  protracted  post-partum 
haemorrhage.  J:  They  may  also,  rarely,  complicate  the  puerperal 
state. 

Typhus  fever  manifests  a  less  marked  tendency  to  the  induction  of 
abortion  or  of  premature  delivery  than  either  typhoid  or  relapsing 
fever,  probably  because  it  is  less  frequently  accompanied  by  metrorrha- 
gia.* It,  however,  occasionally  produces  these  results,  thereby  essen- 
tially increasing  the  danger  of  a  lethal  termination.  || 

Typhoid  fever  is  frequently,  and  relapsing  fever  almost  constantly, 
accompanied  by  abortion  or  by  premature  delivery  induced  by  jDrofuse 
uterine  haemorrhages,^  and  thus  greatly  endanger  life.  The  clinical 
history  and  the  treatment  of  the  fevers  in  question  are  unaffected  by 

*  Schroeder,  "Lehrb.  d.  Geburtsh.,"  18'72,  p.  365.  f  Hennig,  loc.  cit. 

:j:  Wallichs,  "Monatsschr.  f.  Geburtsk  ,"  xxx,  II.  iv,  1867,  p.  253;  Spiegelberg 
"  Ilandb.  d.  Geburtsh.,"  p.  260. 

*  Zuelzer,  "  Monatsschr.  f.  Geburtsk.,"  xxxi,  11.  vi,  1868,  p.  419. 

I  Wallichs,  op.  cit.,  p.  261.  ^  Zuelzer,  op.  cit.,  p.  424. 


254 


THE  PATHOLOGY  OF  PREGNANCY. 


coexisting  pregnancy  except  in  so  far  as  symptoms  and  indications 
having  reference  to  the  occurrence  of  metrorrhagia,  abortion,  or  pre- 
mature delivery,  are  concerned. 

Malarial  Fever. — Malarial  fever  is  not  a  very  frequent  complication 
of  pregnancy,  perhaps  because  the  latter  secures  a  certain  freedom 
from  exposure  to  the  malarial  poison.  Women  who  have  previously 
experienced  malarial  fever,  and  who  have  been  considered  cured  of  the 
disease  for  several  years,  often  suffer  a  relapse  during  subsequent  preg- 
nancies.* Attacks  occurring  under  these  circumstances  may  be  re- 
garded as  acute  exacerbations  of  a  chronic  malarial  disease  which  has 
remained  latent  for  a  certain  time.  Malarial  fever  does  not  produce 
abortion  except  in  rare  instances,  f  even  when  the  febrile  phenomena 
persist  up  to  the  termination  of  pregnancy.  Parturition  suspends  the 
periodic  paroxysms,  supposing  them  to  have  continued  up  to  confine- 
ment, possibly  owing  to  the  loss  of  blood  dependent  on  delivery. 
During  the  puerperal  state,  however,  particularly  in  the  second  and 
third  weeks,  the  paroxysms  usually  return  or  a  latent  malarial  cachexia 
may  manifest  itself  in  the  manner  previously  alluded  to.  J  The  disease 
may  be  communicated  to  the  foetus,  as  has  been  proved  by  the  detec- 
tion of  the  characteristic  pathological  appearances  induced  by  mala- 
rial poisoning  in  the  spleen,  and  by  the  discovery  of  malarial  pigment- 
granules  in  the  blood  and  skin  of  children  dying  before  or  immediately 
after  birth.* 

Hubbard  ||  reported  an  interesting  case  of  intra-uterine  malarial 
fever  of  the  tertian  type,  in  which  the  fetal  movements  were  entirely 
suspended  during  the  maternal  paroxysms,  and  returned  during  the 
intermissions.  The  woman  was  confined  during  an  intermission.  On 
the  following  day  the  mother  and  child  had  a  simultaneous  paroxysm. 
Quinia  was  now  administered,  with  the  result  of  curing  both  mother 
and  child — the  latter  obtaining  the  antiperiodic  through  the  medium 
of  the  mother's  milk. 

The  usual  course  of  malarial  fever  is  altered  by  coexisting  preg- 
nancy. Intermissions  are  usually  wanting,  and  the  fever  becomes 
continued  or  remittent,  the  chills  occurring  irregularly."^  Even  those 
cases  which  most  nearly  approximate  the  usual  malarial  course  show 
a  tendency  to  anticipation  or  retardation  of  the  paroxysms.  The  fever 
may  assume  a  pernicious  character,  its  tendency  in  this  direction  being 
accounted  for  by  the  nervous  prostration  and  anaemia  attendant  upon 
the  puerperal  condition.    Quinia  best  controls  the  febrile  phenomena, 

*  Robert  Barnes,  "Trans,  of  the  Am.  Gyn.  Soc,"  1876,  p.  144. 

f  Max.  Runge,  Volkmann's  "  Samml,  klin.  Vortr.,"  No.  174,  p.  10,  1376. 

jj.  Spiegelberg,  "  Gcburtsh.,"  p.  261.  *  Max  Runge,  loc.  cit. 

|j  Hubbard,  "Edinburgh  Med.  Jour.,"  June,  1866. 

^  Mendel,  "  Intermittens  wiihrend  Schwangcrschaf t  und  Wochenbctt,"  "  Monatsschr. 
f ,  Geburtsk.,"  Bd.  xxxii,  H.  i,  p.  10. 


THE  MANAGEMENT  OF  PREGNANCY. 


115 


CHAPTER  VI. 

THE  MANAGEMENT  OF  PREGNANCY. 

Ilygicne  of  pregnancy. — The  disorders  of  pregnancy. — The  blood-changes  of  pregnancy. 
— Pernicious  anaemia. — Hydraemic  oedema. — Varicose  veins. — Nausea  and  vomiting. 
— Heart-burn. — Insalivation. — Pruritus. — Face-ache. — Cephalalgia. — Insomnia. 

Ix  studying  the  effects  of  pregnancy  we  saw  that,  besides  the  local 
changes  in  the  sexual  apparatus  and  the  disturbances  produced  by 
pressure,  the  organism  had  to  adapt  itself  to  a  variety  of  new  condi- 
tions, of  which  the  most  conspicuous  were  alterations  in  the  quality  of 
the  blood  and  increase  of  its  quantity,  with  additional  work  thrown 
upon  the  lungs  and  kidneys,  and  reflex  derangements  of  the  nervous 
and  digestive  systems.  The  physiological  condition  of  the  pregnant 
woman  approximates  so  closely  to  what  would  be  regarded  as  patholog- 
ical at  other  times  that  the  necessity  arises  for  the  patient  to  carefully 
observe  hygienic  rules,  while  the  physician  often  finds  himself  called 
upon  to  exercise  his  art  in  restraining  distressing  symptoms  within 
limits  consistent  with  the  healthy  progress  of  gestation. 

The  Hygiene  of  Pregnancy. — During  the  pregnant  state,  the  in- 
creased elimination  of  carbonic  acid  by  the  lungs  is  necessarily  associ- 
ated with  increased  consumption  of  oxygen.  This  respiratory  activity 
makes  an  abundance  of  fresh,  pure  air  a  matter  of  prime  importance. 
As  a  rule,  therefore,  a  rural  neighborhood  is  more  conducive  to  nor- 
mal pregnancy  than  large  cities.  To  be  avoided  are  small,  close,  heated 
rooms,  confinement  in-doors,  and  crowded  assemblages. 

The  dietary  should  embrace  all  nutritious,  easily-digested  articles 
of  food.  The  natural  tendency  to  acidity,  heart-burn,  flatulence,  and 
colic  is  apt  to  be  increased  by  indulgence  in  the  products  of  the  frying- 
pan  and  the  dainties  of  the  pastry-cook  and  confectioner.  The  con- 
suming desire  for  unwonted  articles  of  food,  which  is  customarily 
termed  longings,"  I  have  never  yet  witnessed,  and  am  tempted  to 
regard  as  in  a  great  measure  mythical.  A  good  appetite  is  the  best 
safeguard  against  most  of  the  discomforts  of  pregnancy.  Owing,  how- 
ever, to  the  activity  of  the  assimilative  processes,  a  very  moderate  ap- 
petite is  not  incompatible  with  a  considerable  gain  in  weight.  A  very 
large  appetite  is  not  normal  during  pregnancy,  and  requires  to  be 
restrained. 

The  dress  should  be  loose  and  easy.  Garters  and  tight  corsets 
should  be  discarded.    When  the  projection  of  the  abdomen  removes 


116 


PREGNANCY. 


the  folds  of  the  dress  from  the  lower  limbs,  flannel  drawers  reaching 
to  the  waist  should  be  worn  as  a  protection. 

Gentle  exercise,  not  pushed  to  the  verge  of  fatigue,  should  be  en- 
couraged. Walks  and  drives  in  the  fresh  air  are  the  best  means  of 
fostering  sleep  and  maintaining  the  appetite  and  general  assimilative 
processes.  Violent  exercise,  on  the  other  hand,  is  liable  to  produce 
miscarriage.  It  is  stated  that  the  predisposition  to  miscarriage  is 
greatest  at  the  third  and  seventh  month.  Throughout  pregnancy 
special  care  should  be  observed  at  the  recurrence  of  the  menstrual 
epochs.  Long  railway  journeys  at  such  times  are  a  frequent  cause  of 
trouble.  Marital  relations,  though  not  absolutely  to  be  prohibited, 
should  be  of  infrequent  occurrence.  Excesses  in  the  newly  married 
are  a  common  source  of  abortion. 

The  skin  should  be  kept  in  good  condition  by  frequent  bathing,  as 
by  its  eliminative  action  it  is  capable  of  relieving  the  kidneys  of  a  i^or- 
tion  of  the  work  thrown  upon  them.  The  increased  vaginal  secretion 
renders  it  important  for  the  woman  to  frequently  wash  the  external 
genitals.  The  vaginal  douche  is  a  source  of  comfort  to  many  women, 
but  the  quantity  injected  should  not  exceed  a  pint  of  water,  and  should 
be  introduced  slowly,  with  every  precaution  in  the  way  of  allowing 
an  immediate  reflux  to  take  place. 

The  increased  irritability  often  observable  in  pregnant  women  calls 
for  the  greatest  forbearance  and  gentleness  on  the  part  of  those  who 
are  brought  into  close  contact  with  them.  Their  unreasonableness  is 
not  to  be  cured  by  either  impatience  or  stern  treatment.  It  is  the 
product  of  nervous  derangement,  and  is  to  be  regarded  as  due  rather  to 
johysical  than  to  moral  fault. 

The  Disorders  of  Pregnancy.  —  Among  women  reared  amid  the 
refinements  of  civilization  the  entire  period  of  pregnancy  is  very  fre- 
quently attended  with  a  great  deal  of  discomfort.  The  attempt  to 
relieve  the  disorders  of  pregnancy  seriatim^  it  should  be  stated  in  a 
general  way,  is  a  vain  undertaking,  and  is  a  good  method  to  beget  hys- 
teria by  fixing  the  female's  attention  upon  minor  ailments.  The  best 
medicine,  in  a  large  proportion  of  cases,  is  to  devise  amusements  and 
occupations  calculated  to  produce  a  forge tfulness  of  self.  When, 
however,  the  disorders  of  pregnancy  advance  beyond  the  stage  of  dis- 
comfort to  that  of  actual  suffering  or  danger,  every  effort  should  be 
put  forth  for  their  relief  or  mitigation. 

The  Blood-Changes  of  Pregnancy. — The  most  important  changes 
consist  in  the  loss  of  red  corpuscles  and  albumen.  The  former,  as 
the  oxygen-carriers  to  the  tissues,  are  illy  spared  from  the  economy. 
When  they  have  undergone  destruction  to  any  material  extent,  the 
cell-elements,  whose  vitality  is  intimately  associated  with  the  power  to 
take  oxygen  from  the  blood,  suffer  from  inanition,  and  the  starved 
cells  waste  or  fill  with  fatty  molecules.    These  changes  are  of  neces- 


THE  MANAGEMENT  OF  PREGNANCY. 


117 


sitv  followed  by  loss  of  weight,  muscular  prostration,  impaired  func- 
tional activity  of  tlie  secretory  organs,  and  increased  nerve  irritability. 
As  a  consequence,  the  appetite  fails,  the  digestion  is  weakened,  neural- 
gic pains  develop,  and  even  moderate  muscular  exertion  is  attended  with 
effort  and  follow^ed  by  a  sense  of  fatigue  ;  vertigo,  loss  of  memory,  and, 
in  severe  cases,  chorea,  hysteria,  and  insanity,  may  result  from  the 
deranged  condition  of  the  nerve-centers  ;  attacks  of  syncope,  palpita- 
tions, and  praecordial  oppression  point  to  feeble  heart-action ;  the  arte- 
rial tension  is  lowered  and  venous  hypergemia  results  ;  and,  finally,  the 
stagnant  blood,  deprived  of  its  albumen,  in  place  of  inviting  endos- 
motic  currents,  transudes  through  the  walls  of  the  vessels,  giving  rise 
to  oedema  and  dropsical  effusions.  Gusserow*  (1871)  called  attention 
to  the  fact  that  the  anaemia  of  pregnancy  might  progress  to  such  an 
extreme  as  to  produce  a  fatal  termination. 

The  treatment  of  anaemia  is  largely  prophylactic.  Light,  air, 
moderate  exercise,  good  food,  regulation  of  the  bowels,  cheerful  society, 
and  an  occasional  respite  from  household  and  family  cares,  will  always 
be  the  main  checks  to  its  extreme  development.  Iron,  though  of  little 
avail  in  repairing  losses  which  have  already  taken  place,  is  of  the  ut- 
most value  in  limiting  the  progress  of  the  malady.  Iron  reduced  by 
hydrogen,  in  three-grain  doses,  either  alone  or  combined  with  a  fiftieth 
of  a  grain  of  arsenic,  has  rendered  me  most  service  in  this  affection. 
It  should,  however,  be  continued  without  intermission  for  weeks  at  a 
time  in  order  to  obtain  the  full  advantage  of  its  beneficent  action. 
The  liquid  forms  of  iron,  so  useful  at  other  times,  I  have  rarely  found 
tolerated  for  a  lengthened  period  in  the  pregnant  state.  In  weakened 
states  of  the  stomach,  when  the  latter  revolts  at  beefsteak  and  mutton, 
easily  assimilated  albuminoid  articles,  such  as  milk,  soft-boiled  eggs, 
and  scraped  raw  or  underdone  meat,  should  be  administered  in  small 
but  frequently  repeated  portions.  Where  the  marasmus  is  extreme, 
and  the  rectum  tolerant,  the  stomach  may  be  relieved  of  a  part  of  its 
duty  by  the  use  of  nutritive  enemata  prepared  in  accordance  with  the 
now  familiar  prescription  of  Leube.  In  the  pernicious  form  of  anaemia, 
Gusserow  tried  transfusion,  but  without  success.  He  recommended, 
therefore,  the  resort  to  premature  labor.  In  a  case  which  occurred  to 
me  in  hospital  practice,  before  my  attention  was  drawn  to  Gusserow's 
essay,  I  employed  the  latter  method  after  consultation  with  my  col- 
leagues. The  patient  made  a  slow  but  apparently  sure  progress  tow- 
ard recovery,  until,  at  the  end  of  a  month,  she  managed,  in  the  tem- 
porary absence  of  the  ward  nurse,  to  get  out  of  bed  and  make  a 
hearty  meal  of  corned-beef  and  cabbage.  Vomiting  set  in,  followed 
by  collapse,  which  proved  fatal  in  a  few  hours.  This  pernicious 
form  of  anaemia,  though  not  confined  to  multiparae,  develops  most 

*  Gdsserow,  "  Ueber  hocbgradigste  Anaemie  Schwangerer,"  "  Arch,  f .  Gynaek.,"  Bd. 
ii,  p.  218. 


118 


PREGNANCY. 


frequently  in  women  who  have  borne  many  children  in  rapid  suc- 
cession. 

A  not  unusual  result  of  hydraemia  consists  in  a  swelling  of  the 
lower  extremities,  beginning  at  the  ankles,  and  thence  extending  up- 
ward and  invading  often  the  labia,  the  vagina,  and  the  lower  segment 
of  the  uterus.  When  not  associated  with  kidney  complications,  this 
oedema  is  rarely  dangerous,  though  often  the  source  of  extreme  dis- 
comfort. In  some  cases  of  oedema  of  the  vulva,  the  labia  may  attain 
to  the  size  of  a  man's  head,  and  become  nearly  diaphanous  from  the 
serous  infiltration.  When  the  distention  is  extreme,  gangrene  may 
threaten  and  make  it  necessary  to  resort  to  i3uncture.  In  lying-in 
hos^Ditals  this  should  be  done  with  every  antiseptic  precaution.  AVith 
free  drainage  established,  the  swelling  rapidly  subsides.  In  a  half- 
dozen  cases  which  I  have  thus  far  treated  in  this  manner,  premature 
labor  has  followed  in  the  course  of  two  or  three  days,  a  coincidence  of 
such  frequent  occurrence  as  to  make  it  necessary  to  employ  puncture 
with  circumspection. 

(Edema  of  the  lower  extremities  seldom  disappears  entirely  before 
confinement,  though  relief  is  sometimes  exj)erienced  in  the  last  month, 
when  the  fundus  of  the  uterus  falls  forward.  Slight  degrees,  such  as 
swelling  limited  to  the  feet,  making  it  necessary  for  the  woman  to  go 
around  in  old  shoes  or  her  husband's  slippers,  do  not  require  treat- 
ment. Where,  however,  the  skin  of  the  limbs  becomes  tense  and 
painful,  warm  cloths  should  be  applied,  diaphoresis  if  possible  should 
be  induced,  tonics  should  be  administered,  and  the  patient  be  kept  in 
a  recumbent  position,  or  with  the  extremities  raised  a  V Americaine. 
Hydragogue  cathartics,  by  still  further  impoverishing  the  blood,  tend 
to  aggravate  the  difficulty. 

Varicose  Veins. — Varicose  veins  occur  with  greater  frequency  in 
multiparae  than  in  primiparse.  So  long  as  the  large  veins  are  not 
involved,  they  possess  slight  significance.  The  saphena  is  always  first 
affected,  then  the  lateral  branches  upon  the  inner  surface  of  the  leg 
and  thigh,  especially  just  above  the  knee,*  and  less  commonly  the 
veins  of  the  vulva.  Dilatation  of  the  hsemorrhoidal  veins  is  a  very 
frequent  occurrence. 

The  treatment  of  varicose  veins  is  limited  to  the  adoption  of  meas- 
ures to  prevent  their  increase,  and  to  provide  against  the  dangers  of 
rupture.  The  first  indication  is  best  fulfilled  by  regulation  of  the 
bowels  and  the  wearing  of  elastic  stockings.  The  injection  of  one  to 
two  grains  of  ergotine  in  solution  has  been  recommended,  and  is  re- 
ported not  to  awaken  uterine  contractions.  As  the  danger  of  rupture 
is  not  speculative  (Spiegelberg  f  reports  two  cases  of  fatal  haemorrhage 

*  SPIEGELnERG,  loc.  Clt.^  p.  250. 

f  Ibid.^  p.  250.  For  a  complete  discussion  of  the  subject,  vide  "  Des  varices  chez  la 
femmc  enceinte,"    Thbse  d'Agregation,"  par  le  Dr.  P.  Bddin. 


THE  MANAGEMENT  OF  PREGNANCY. 


119 


from  this  cause),  the  patient  should  always  be  provided  with  a  com- 
press and  bandage,  which  she  should  be  taught  to  apply  herself  in  case 
of  a  sudden  emergency  before  professional  aid  can  be  obtained. 

Nausea  and  Vomiting. — There  are  few  known  therapeutical  agents 
which  have  not  at  one  time  or  another  been  essayed  as  remedies  for 
the  nausea  and  vomiting  of  pregnancy.  Some  of  them  have  even  en- 
joyed for  a  time  high  repute  as  specifics,  but  the  sobering  effect  of 
experience  has  invariably  served  to  dispel  illusive  hopes,  the  most  suc- 
cessful of  them  proving  uncertain,  and  of  benefit  to  only  a  limited 
class  of  patients.  It  is  usually,  therefore,  the  part  of  prudence  to  do 
nothing  for  the  minor  degrees  of  the  affection,  such  as  the  ordinary 
morning-sickness,  or  even  for  continuous  nausea,  so  long  as  the  inges- 
tion of  food  and  the  general  nutrition  of  the  patient  are  undisturbed. 
For  these  cases  Seyfert's  advice  to  let  the  wife  go  home  on  a  visit  to 
her  mother,  implying  the  value  of  changed  surroundings,  furnishes  a 
serviceable  hint  in  the  way  of  practice.  When,  however,  the  distress- 
ing symptoms  continue  after  the  first  three  months,  and  perceptibly 
tend  to  exhaust  the  vital  powers,  every  resource  should  be  tried  in 
turn,  in  the  hope  that  some  one  of  the  many  in  repute  may  prove  of 
service  as  a  means  of  warding  off  impending  disaster. 

At  the  outset  of  any  systematic  plan  of  treatment  for  pregnancy- 
vomiting,  it  is  essential  that  the  physician  should  inspire  his  patient 
with  confidence  in  his  ultimate  success.  Care  should  be  taken  to  reg- 
ulate the  bowels,  as  constipation  invariably  aggravates  existing  gastric 
disturbance.  If,  in  the  early  months,  the  uterus  is  found  retroverted 
or  retroflexed,  it  should  be  replaced  in  the  knee-chest  position,  and 
the  recurrence  of  the  displacement  should  be  prevented  by  a  suitable 
pessary.  A  speculum  examination  should  be  made  of  the  cervix,  and, 
should  it  be  found  eroded,  the  raw  surface  should  be  brushed  at  inter- 
vals of  from  two  to  three  days  with  a  ten-per-cent.  solution  of  nitrate 
of  silver.  In  quite  a  number  of  cases  a  mitigation  of  the  distress  is 
obtained  by  applying  the  faradaic  current  to  the  pit  of  the  stomach  ; 
in  others,  the  ice-bag  applied  to  the  cervical  vertebrae  affords  a  con- 
siderable measure  of  relief.  The  inhalation  of  oxygen  has  likewise 
been  tried  by  Pinard  with  success.  To  many,  ice-cold  effervescent 
drinks  are  grateful.  Dr.  Fordyce  Barker  recommends  carbonic-acid 
water  containing  a  drachm  of  bromide  of  potassium  to  the  siphon.  Dry 
champagne  is  of  assistance  to  a  comparatively  small  class,  but  more 
often  I  have  found  it  revolting  to  a  squeamish  stomach.  Of  medicinal 
agents,  subnitrate  of  bismuth  and  the  oxalate  of  cerium  possess  the 
widest  application.  Usually  I  order  ten  grains  of  the  former,  com- 
bined with  five  to  ten  grains  of  the  latter,  to  be  taken  ten  minutes  be- 
fore eating.  In  cases  of  gastric  catarrh,  my  favorite  is  the  tincture  of 
nux  vomica  given  in  ten-drop  doses  before  meals.  Drop-doses  of 
Fowler's  solution  at  meal-time  are  said  to  exert  considerable  influence 


120 


PREGNANCY. 


in  allaying  stomach  irritability.  A  twelfth  of  a  grain  of  morphia  given 
hypodermically  or  by  the  mouth  will  frequently  aid  the  retention  of 
food  by  the  stomach,  but  may  lead  to  the  formation  of  the  opium- 
habit.  Simmons,  of  Yokohama,  recommends  the  injection  of  thirty 
grains  of  chloral  per  rectum  morning  and  evening,  a  practice  of  which 
Eichardson  advises  further  trial.*  After  eating,  digestion  may  be 
promoted  by  ten  grains  of  pepsin,  given  alone  or  with  either  the  dilut3 
muriatic  acid  or  Horsford's  acid  phosphate,  f 

If  the  foregoing  measures  prove  of  no  avail,  the  patient  should  be 
made  to  take  small  quantities  of  easily  digested  food,  such  as  milk 
and  lime-water,  Valentine's  beef-juice,  or  the  pulp  scraped  from 
raw  or  underdone  beef,  at  hourly  intervals,  while  rest  in  bed  is  main- 
tained for  the  purpose  of  avoiding  the  slightest  unnecessary  waste  of 
tissue. 

When  the  vomiting  is  literally  uncontrollable,  a  rare  event  in 
cases  where  tho  physician  commands  the  full  cooperation  of  his 
patient,  and  death  from  starvation  threatens,  there  remains  as  an 
ultimate  resource  the  artificial  induction  of  abortion,  or  premature 
labor.  Before,  however,  proceeding  to  this  last  extreme,  it  is  proper 
to  remember  that,  in  many  cases,  the  vomiting  stops  spontaneously 
after  the  termination  of  the  third  month,  or,  when  more  persistent, 
after  the  sixth  month  of  pregnancy ;  and  that  furthermore,  where 
practicable,  it  should  be  the  rule  to  postpone  measures  for  emptying 
the  uterus  until  after  the  child  has  become  viable.  Now,  where  it  is 
necessary  to  maintain  the  strength  of  the  patient  for  two  or  three 
weeks  only  in  the  hope  of  obtaining  a  living  child,  or  a  natural  sub- 
sidence of  the  disorder,  rectal  alimentation  is  capable  often  of  ren- 
dering excellent  service.];  Milk,  eggs,  and  defibrinated  blood  *  may 
be  used  for  this  purpose,  though  I  have  found  nothing  so  effective  as 
the  beef  and  pancreas  preparation  of  Leube.  [   Dr.  Henry  F.  Campbell 

*  Richardson,  "  Ilj-dratc  of  Chloral  in  Obstetric  Practice,"  "  Trans,  of  the  Am. 
Gyngec.  Soc,"  vol.  i,  p.  247. 

f  Dr.  E,  CoPEMAN  recommends  dilatation  of  the  os  externum  and  cervical  canal  with 
the  index-finger.  The  latter  should  be  passed  to  the  first  joint,  but  not  up  to  the  os  in- 
ternum. This  method,  which  bears  Dr.  Copeman's  name,  is  regarded  by  its  author  as 
infallible.  It  has  likewise  received  the  enthusiastic  indorsement  of  Dr.  Marion  Sims. 
— ("  Arch,  of  Med.,"  vol.  iii.) 

:}:  Dr.  BusEY,  in  an  article  published  in  the  "Am.  Jour,  of  the  Med.  Sci.  "  (1819,  pp. 
n 2-117),  recommends  stomach-rest,  nutritive  enemata,  and  the  rectal  administration 
of  bromide  of  potassium. 

*  To  prevent  decomposition,  Dr.  A.  II.  Smith  advises  the  addition  of  a  grain  and  a 
half  of  chloral  to  each  fluidounce  of  the  blood. 

II  Leube's  formula  consists  of  five  to  ten  ounces  of  fincl3'-chopped  beef,  to  which 
should  be  added  one  third  its  weight  of  finely-minced  pancreas  (pig  or  ox).  The  mixture 
should  be  treated  in  a  mortar  with  five  ounces  of  lukewarm  water,  and  reduced  to  a 
thick  soup  (Foster's  "  Clinical  Medicine,"  p.  24).  Not  more  than  four  to  six  ounces 
should  be  given  at  a  time,  nor  more  frequently  than  once  in  four  hours. 


THE  MANAGEMENT  OF  PREGNANCY. 


121 


relates  a  case  where  a  patient  of  his  was  nourished  for  fifty-two  days 
by  rectal  alimentation  alone.*  Such  cases,  however,  are  very  rare, 
owing,  in  my  experience  at  least,  to  the  fact  that  in  time  the  rectum 
becomes  intolerant  of  the  presence  of  the  injected  materials.  As  the 
induction  of  abortion,  or  premature  labor,  always  subjects  the  operator 
to  criticism,  and  as  its  performance  is  by  no  means  unattended  with 
risk  to  life,  it  is  advisable  to  share  the  responsibility  with  an  experi- 
enced professional  colleague. 

Heart-burn. — Heart-burn  becomes  distressing  in  the  later  months  of 
pregnancy.  It  can  rarely  be  cured  before  delivery,  but  may,  in  most 
cases,  be  palliated  by  carbonate  of  magnesia,  or  half-teaspoonful  doses 
of  aromatic  spirits  of  ammonia. 

Insalivation. — Excessive  flow  of  saliva  to  the  extent  of  two  to  three 
quarts  in  the  course  of  the  day  has  been  observed.  For  this  dis- 
order small  doses  of  atropia,  the  twelfth  of  a  grain  of  pilocarpine,  and 
the  fluid  extract  of  viburnum  prunifolium  have  been  severally  recom- 
mended. 

Pruritus. — Pruritus,  without  any  visible  affection  of  the  skin, 
sometimes  occasions  in  pregnant  women  an  unendurable  degree  of 
suffering.  When  general,  a  temporary  relief  may  be  obtained  by  plac- 
ing the  patient  in  a  prolonged  soda-bath,  and  subsequently  rubbing 
the  entire  surface  with  vaseline.  Very  commonly  the  itching  is  con- 
fined to  the  distended  abdominal  walls.  In  such  cases,  cloths  wet 
with  camphor-liniments,  with  the  addition  of  chloroform  (lin.  saponis 
comp.,  I  V  ;  chloroformi,  ^  j)>  or  a  solution  of  carbolic  acid  (  3  j  ad  Oj) 
applied  to  the  itching  surface  will  usually  allay  the  irritation  for  the 
time.  In  pruritus  of  the  vulva,  in  addition  to  local  external  applica- 
tions, great  pains  should  be  taken  to  cleanse  the  vagina  with  solutions 
of  borax  or  carbolic  acid.  A  half-pint  slowly  injected  into  the  vagina 
may  be  employed  twice  daily,  without  risk  of  provoking  labor.  If 
the  itching  results  from  an  acrid  discharge  proceeding  from  an  ulcer- 
ated cervix,  the  application  of  nitrate  of  silver  and  the  introduction 
at  night  of  a  cotton  plug  soaked  in  a  solution  of  tannin  in  glycerine 
(ac.  tannic,  3  j  ;  glycerinae,  |  j)  will  usually  afford  relief. 

Face-ache. — Neuralgia  of  the  fifth  nerve  is  a  common  affection  in 
pregnant  women.  It  can  often  be  quieted  by  the  external  application 
of  aconite,  chloroform,  or  camphor  liniment.  Should  these  or  kindred 
remedies  fail,  it  is  best  to  resort  at  once  to  the  hypodermic  injection 
of  morphia.  The  recurrence  of  pain,  as  the  effects  of  the  morphia 
pass  away,  can  in  most  cases  be  prevented  by  giving  to  the  patient 
once  in  four  hours  from  three  to  five  drop  doses  of  the  fluid  extract  of 
gelsemium,  suspending  its  administration  so  soon  as  the  slightest  in- 
dication of  ptosis  is  produced.    Croton-chloral,  in  from  two-  to  five- 

*  H.  F,  Campbell,  "Rectal  Alimentation  in  Pregnancy,"  "Trans,  of  the  Am.  Gyn. 
See,"  vol.  iii,  p.  273. 


122 


LABOR. 


grain  doses  hourly,  has  likewise  proved  effective.  Bartholow  advises 
not  to  push  the  remedy  beyond  fifteen  grains.  Lindner  (^^  Arch.  f. 
Gynaek./'  Bd.  xvi,  p.  312)  recommends  ten  grains  at  a  dose  given  at 
bedtime. 

Cephalalgia. — Headache  should  be  treated  according  to  the  cause. 
Constipation  should  be  removed,  and  iron  should  be  given  when  the 
headache  is  dependent  upon  anaemia.  If  of  malarial  origin,  I  have 
never  hesitated  to  give  quinine  in  large  doses,  and  have  never  yet  ob- 
served its  acting  as  an  oxytocic.  When  purely  of  reflex  origin,  the 
guarana-powder,  the  diffusible  stimulants,  and  the  entire  range  of 
nerve  sedatives  are  indicated.  Unfortunately,  there  are  no  fixed  rules 
by  which,  in  a  given  case,  the  appropriate  remedy  can  be  invariably 
selected. 

Insomnia. — Troublesome  sleeplessness  may  toward  the  end  of  preg- 
nancy reduce  a  woman  to  an  unfavorable  condition  for  encountering 
the  perils  of  childbirth.  The  main  reliance  should  be  placed,  where 
possible,  upon  moderate  exercise,  upon  bromide  of  potassium,  chloral, 
camphor  and  hyoscyamus,  and  codeine.  The  ordinary  forms  of  opium 
should  be  placed  under  the  ban,  on  account  of  the  fatal  facility  with 
which  the  opium-habit  is  acquired.  Even  in  ordering  the  less  ob- 
jectionable hypnotics,  care  should  be  taken  against  their  continued 
employment.  With  proper  caution,  however,  their  occasional  admin- 
istration for  the  purpose  of  breaking  a  morbid  habit  is  to  be  com- 
mended. 


LABOR 


CHAPTER  VII. 

THE  PHYSIOLOGY  OF  LABOR  AND  ITS  CLINICAL  PHENOMENA. 

Causes  of  labor. — Uterine  contractions. — Action  of  labor-pains  upon  the  uterine  walls. — 
Contraction  of  ligaments. — Action  of  abdominal  muscles. — Action  of  vagina. — The 
pain  of  labor. — General  influence  of  labor-pains  upon  the  organism. — Precursory 
symptoms  of  labor.— First,  second,  and  third  stages  of  labor.— Duration.— Action  of 
the  expellent  forces. 

Under  the  term  lahor  are  comprised  all  the  physiological  and  me- 
chanical processes  by  means  of  which  the  extrusion  of  the  ovum  from 
the  maternal  organs  of  generation  is  effected.  As  the  term  implies 
exertion,  its  application  is  restricted  to  the  parturient  efforts  of  vi- 
viparous animals.    The  duration  of  pregnancy  varies  widely  in  the 


PHYSIOLOGY  OF  LABOR  AND  ITS  CLINICAL  PHENOMENA.  123 


different  classes  of  the  animal  kingdom.  The  occurrence  of  normal 
labor  is  coincident  with  the  maturity  of  the  foetus.  This,  in  man,  is 
found  to  correspond  very  nearly  to  the  interval  between  ten  menstrual 
i^eriods. 

Causes  of  Labor. 

Speculation  as  to  the  proximate  causes  of  labor  have  so  far  proved 
profitless.  The  following  particulars  comprise  the  extent  of  our 
knowledge  of  the  conditions  which  prepare  the  way  during  pregnancy 
for  the  final  expulsive  efforts  : 

1.  During  the  first  three  months  the  growth  of  the  uterus  is  more 
rapid  than  that  of  the  ovum,  which  is  freely  movable  within  the  uter- 
ine cavity,  except  at  its  jDlacental  attachment.  In  the  fourth  month 
the  reflexa  becomes  so  far  adherent  to  the  chorion  that  it  can  only  be 
separated  by  the  exertion  of  some  slight  degree  of  force,  and  the  am- 
nion is  in  contact  with  the  chorion.  After  the  fourth  month  the 
chorion  and  amnion  are  agglutinated  together,  though  even  at  the  ter- 
mination of  pregnancy  they  may  with  care  be  separated  from  one 
another.  After  the  fifth  month  the  agglutination  of  the  decidua  vera 
and  reflexa  takes  place.  In  the  second  half  of  pregnancy  the  rapid 
development  of  the  ovum  causes  a  corresponding  expansion  of  the 
uterine  cavity,  the  uterine  walls  becoming  thinned,  so  that  by  the  end 
of  gestation  they  do  not  exceed  upon  the  average  two  to  three  lines  in 
thickness.  The  vast  extension  of  the  uterine  surface  is  not,  however, 
simply  a  consequence  of  over-stretching,  a  fact  shown  by  the  circum- 
stance that  the  uterus  toward  the  close  of  gestation  is  increased  nearly 
twenty-fold  in  weight,  and  by  the  histories  of  extra-uterine  fetations, 
in  which,  up  to  a  certain  limit,  the  uterus  enlarges  progressively,  in 
spite  of  the  non-presence  of  the  ovum.  The  augmented  weight  of 
the  uterus  is  the  result  of  the  increase  in  length  and  width  of  the  indi- 
vidual muscular  fiber-cells,  the  extreme  vascular  development,  and 
the  abundant  formation  of  connective  tissue.  Up  to  the  sixth  and  a 
half  month  there  has  further  been  observed  a  genesis  of  new  fiber- 
cells,  especially  upon  the  inner  uterine  surface.  According  to  Ranvier, 
the  smooth  muscular  fibers  become  striated  as  the  end  of  gestation  is 
reached.* 

The  precise  manner  in  which  the  distention  of  the  uterus  is  accom- 
plished has  as  yet  not  been  demonstrated.  A  2?riori  only  two  possibil- 
ities are  apparently  admissible,  viz.,  either  the  individual  structure 
elements  are  stretched  after  the  manner  of  elastic  bands,  or  a  rear- 
rangement of  the  muscular  elements  takes  place  in  such  wise  that  a 
certain  proportion  of  the  fiber-cells,  instead  of  lying,  as  in  the  begin- 
ning of  pregnancy,  parallel  to  one  another,  gradually,  with  the  ad- 
vance of  gestation,  are  displaced,  so  that  the  ends  only  are  in  juxta- 
position.   It  is  probable,  though  not  proved,  that  toward  the  close 

*  Vide  Tarnier  ct  Chantreuil,  "  Traite  de  I'art  des  accouchements,''  p.  203. 


124 


LABOR. 


the  thinning  of  the  walls  is  the  result  of  both  conditions.  Bearing 
these  premises  in  mind,  it  becomes  a  disputed  question  as  to  whether 
one  of  the  causes  of  labor  is  not  to  be  found  in  the  reaction  of  the 
uterus,  as  a  hollow  muscular  organ,  from  the  extreme  tension  to  which 
its  fibers  are  ultimately  subjected.  Countenance  to  the  affirmative 
side  is  afforded  by  the  tendency  to  premature  labor  in  hydramnion  and 
multiple  pregnancies,  in  which  a  high  degree  of  tension  is  reached  at 
a  period  considerably  antedating  the  complete  development  of  the 
foetus. 

2.  There  is  a  perceptible  increase  of  irritability  in  the  uterus  from 
the  very  beginning  of  gestation.  Indeed,  the  facility  with  which  con- 
tractions may  be  produced  by  manipulating  the  organ  through  the 
abdominal  walls  has  been  put  forward  by  Braxton  Hicks  as  one  of 
the  distinguishing  signs  of  pregnancy.  This  irritability  is  especially 
marked  at  the  recurrence  of  the  menstrual  epochs,  and  becomes  a  more 
and  more  prominent  feature  in  the  latter  months,  when  spontaneous 
painless  contractions  are  ordinary  incidents  of  the  normal  condition. 

3.  The  researches  of  Friedliinder,  Kundrat,  Engelmann,  and  Leo- 
pold have  demonstrated  that  the  decidua  vera  of  pregnancy  is  dis- 
tinguishable into  an  outer,  dense,  membranous  stratum,  composed  of 
large  cells  resembling  pavement  epithelia,  probably  metamorphosed 
cylindrical  cells,  and  an  —  in  appearance  —  underlying  mesh-work, 
formed  from  the  walls  of  the  enlarged  decidual  glands.  It  is  in 
this  spongy  layer  that  the  separation  of  the  decidua  takes  place,  the 


FiQ.  72.— The  mucous  membrane  of  the  uterus.  A,  amnion  ;  reflcxa  ;  Z>,  decidua  vera  ; 
D,  R,  glandular  spaces  of  the  lower  stratum  ;  J/,  muscular  structure  of  uterus.  (Engel- 
mann.) 

fundi  of  the  glands  persisting,  even  after  the  expulsion  of  the  ovum. 
By  many,  a  fatty  degeneration  of  the  cells  of  the  decidua  has  been 
observed  toward  the  end  of  pregnancy,  but  Leopold,  Dohrn,  and 
Langhans  have  shown  that  this  is  not  of  constant  occurrence.*  The 

*  Leopold,  "  Studien  iibcr  die  Schlcimhaut,"  etc.,  "  Arch.  f.  Gynaek.,"  Bd.  xi,  p.  49. 


PHYSIOLOGY  OF  LABOR  AND  ITS  CLINICAL  PHENOMENA.  125 


trabeculce  which  inclose  the  spaces  of  the  net- work  diminish  in  size 
with  the  advance  of  pregnancy.  Thus,  while  they  measure  at  the 
fourth  month  about  of  an  inch  in  thickness,  they  become  gradu- 
ally reduced  in  the  subsequent  months  to  ytito  of  an  inch,  a  change 
which  materially  facilitates  the  peeling  off  of  the  decidual  surface.* 

4.  From  the  fifth  month  onward,  large-sized  cells  make  their 
appearance  in  the  serotina,  especially  in  the  neighborhood  of  thin- 
walled  vessels.  The  largest  of  these  so-called  giant-cells  contain  some- 
times as  many  as  forty  nuclei.  Though  a  physiological  product,  they 
resemble  for  the  most  part  the  so-called  specific  cancer-cells  of  the  older 
writers.  They  are  of  special  obstetrical  interest  from  the  fact  observed 
by  Friedliinder,  and  confirmed  by  Leopold,!  that  they  penetrate  the 
uterine  sinuses  from  the  eighth  month,  and  lead  to  coagulation  of  the 
blood,  and  to  the  formation  of  young  connective  tissue,  by  means  of 
which  a  portion  of  the  venous  sinuses  becomes  obliterated  before  labor 
begins.  The  subtraction  of  these  vessels  from  the  circulation  tends  to 
increase  the  amount  of  the  venous  blood  in  the  intervillous  spaces  of 
the  placenta. 

5.  It  is  proper  to  recall  here  the  fact  that  the  nerve-filaments  of  the 
uterus  are  derived  in  principal  measure  from  the  sympathetic  system. 
The  large  cervical  ganglion,  which  in  pregnancy  measures  about  two 
inches  in  length  by  one  and  a  half  inch  in  breadth,  receives,  however, 
in  addition  to  the  sympathetic  fibers,  the  second,  third,  and  fourth 
sacral  nerves. 

Physiology  has  as  yet  left  unsettled  the  question  as  to  the  main 
channels  of  the  motor  impulses  which  are  conveyed  to  the  uterus  during 
labor.  One  of  my  hospital  patients,  Avith  paralysis  of  the  lower  ex- 
tremities, retention  of  urine,  and  loss  of  power  over  the  sphincter-ani 
muscle,  had  a  perfectly  natural  though  painless  labor.  The  cause  of 
the  paralysis  was  obscure,  the  patient  subsequently  making  a  complete 
recovery.  Jacquemart  I  reports  a  similar  case,  in  which  the  paralysis 
was  due  to  partial  compression  of  the  cord  at  the  level  of  the  first 
dorsal  vertebra.  On  the  other  hand,  Schlesinger  has  shown  that  the 
sympathetic  is  not  the  only  motor  nerve,  as  reflex  movements  of  the 
uterus  follow  stimulation  of  the  organ  when  all  the  branches  of  the 
aortic  plexus  have  been  carefully  divided. 

A  motor  center  for  uterine  contractions  has  been  proved  to  exist  in 
the  medulla  oblongata.  This  center  is  excited  directly  to  action  by 
anaemic  conditions,  and  by  the  presence  of  carbonic  acid  in  the  blood 
conveyed  to  it.  Vivid  mental  emotions  may  either  awaken  or  suspend 
uterine  contractility. 

*  Engelmann,  **  The  Mucous  Membrane  of  the  Uterus,"  p.  45. 
f  Op.  cit.,  pp.  492,  et  seg. 

X  Tarnier  et  Chantreuil,  "  Traite  de  I'art  des  accouchements,"  p.  229. 

*  Oder  und  Schlesinger,  Strieker's  "  Wiener  med.  Jahrbuch,"  18'72. 


126 


LABOR. 


Reflex  movements  of  the  uterus  may  be  provoked  by  stimulating 
the  central  end  of  any  of  the  spinal  nerves,  a  fact  which  serves  to  ex- 
plain the  consensus  long  recognized  as  existing  between  the  breasts 
and  the  organs  of  generation.  When  the  spinal  cord  is  divided  below 
the  medulla  oblongata,  this  phenomenon  is  no  longer  observed.  Direct 
stimuli  to  the  uterus,  however,  determine  contractions  independently 
of  the  medulla  oblongata,  the  spinal  cord  then  acting  as  a  reflex  center. 
The  presence  of  asphyxiated  blood  in  the  arterial  trunks  acts  as  a 
physiological  stimulus  to  labor.*  By  the  separation  of  the  decidua 
from  its  organic  connection  with  the  uterus,  the  ovum  acts  as  a 
foreign  body,  and,  as  is  well  known,  speedily  awakens  uterine  move- 
ments. Finally,  Kehrer  f  has  shown  that,  when  a  cornu  is  removed 
from  the  uterus  during  labor,  rhythmic  contractions  of  the  mus- 
cular fibers  will  continue  from  a  half-hour  to  an  hour  after  separa- 
tion, provided  only  the  tissues  be  kept  moist  and  at  a  suitable  tem- 
perature. 

The  following  theory  of  the  causes  of  labor  is  offered,  not  because 
of  its  completeness,  but  merely  as  a  means  of  grouping  the  foregoing 
facts  together  in  the  order  of  their  relative  importance.  The  advance 
of  pregnancy  is  associated  with  increase  in  the  irritability  of  the  uterus, 
a  property  most  pronounced  at  the  recurrence  of  the  menstrual  epochs. 
By  thinning  of  the  partitions  between  the  glandular  structures  the 
way  is  prepared,  as  the  time  for  labor  approaches,  for  the  easy  separa- 
tion of  the  dense  inner  stratum  of  the  decidua.  The  ready  response 
of  the  uterus  to  stimuli  reflected  from  the  peripheral  extremities  of  the 
spinal  nerves,  to  direct  local  irritation,  and  to  the  presence  of  blood 
surcharged  with  carbonic  acid  in  the  uterine  vessels,  explains  the  fre- 
quency of  painless  contractions  for  days,  or  even  weeks,  in  some  cases, 
previous  to  labor.  To  these  means  of  exciting  uterine  motility  there 
should  be  added,  in  all  probability,  the  reaction  of  the  uterine  muscle, 
from  the  tension  to  which  it  is  subjected  by  the  growth  of  the  ovum, 
and  to  circulatory  disturbances  in  the  cerebral  centers  sometimes 
effected  by  vivid  emotions.  Frequently  repeated  uterine  contractions, 
without  partial  separation  of  the  decidua,  are  hardly  comprehensible 
after  the  decidua  vera  and  reflexa  are  brought  into  close  contact  with 
one  another.  Such  a  physiological  separation  would,  of  necessity, 
when  of  sufficient  extent,  by  converting  the  ovum  into  a  foreign  body, 
furnish  an  active  cause  for  the  advent  of  labor,  in  the  same  way  that 
labor  is  prematurely  excited  by  a  similar  separation  when  artificially 
induced.  Thus,  by  the  time  the  development  of  the  foetus  is  com- 
pleted, all  things  are  in  train  for  its  expulsion.  When  other  causes 
do  not  early  operate  as  determining  forces,  the  increase  of  uterine 

*  Vide  ScHLESiNGER,  Strieker's  "  Wiener  mcd.  Jahrbuch,"  1873. 
f  Keurer,  "  Beitriigc  zur  vcrglcichende  und  experimentellen  Geburtskunde,"  2te8 
Ileft,  p.  48. 


PHYSIOLOGY  OF  LABOR  AND  ITS  CLINICAL  niENOMENA.  127 


irritability  at  the  recurrence  of  the  menstrual  epochs  probably  ac- 
counts for  the  ordinary  coincidence  of  labor  Avitli  the  tenth  cata- 
menial  date. 

Physiological  Phen^omena  of  Labor.  ^ 

The  Uterine  Contractions. — The  uterine  contractions  are  entirely 
independent  of  volition.  As  in  other  organs  composed  of  smooth 
muscular  fibers,  each  contraction  at  the  beginning  is  slow  and  weak  ; 
gradually  it  reaches  the  point  of  greatest  intensity  ;  the  acme  con- 
tinues for  a  brief  period,  and  then,  finally,  is  folloAved  by  complete 
relaxation.  Each  complete  excursion  is  termed  a  labor-pain.  Peri- 
staltic movements  have  been  observed  in  animals  with  two-horned 
uteri.  A  similar  action,  proceeding  from  the  fundus  to  the  cervix, 
has  been  sometimes  assumed  for  the  human  subject.  The  peristaltic 
wave,  however,  if,  indeed,  it  exists,  extends  so  rapidly  that  it  is  best 
to  consider  the  uterus  as  a  hollow  muscle,  which  contracts  simulta- 
neously in  all  its  parts.  As  labor  advances,  an  increase  in  the  length 
and  the  force  of  the  contractions  is  developed.  The  stronger  the 
pains,  the  shorter  the  interval  between  them.  The  average  normal 
duration  of  a  labor-pain  is  about  one  minute. 

The  Action  of  Labor-Pains  upon  the  Uterine  Walls. — During  the 
intervals  between  the  pains,  it  is  well  known  that  the  uterus  possesses 
an  ovoid  shape,  and  is  flattened  antero-posteriorly  by  the  pressure  of 


the  abdominal  walls.  During  the  pains,  however,  the  uterus,  as  it 
closes  upon  the  fluid  contents  of  the  ovum,  assumes  a  more  nearly 
globular  outline.  As  a  consequence,  the  transverse  diameter  is  dimin- 
ished, and  the  antero-posterior  increased  in  corresponding  proportion. 
By  this  change,  the  uterus,  which  had  previously  rested  by  its  poste- 


128 


LABOR. 


rior  surface  upon  the  spinal  column,  rises  upward  so  tliat  its  fundus 
produces  a  bulging  of  the  anterior  abdominal  walls. 

Inasmuch  as  the  lower  uterine  segment  progressively  diminishes 
in  thickness  toward  the  cervix,  its  walls  oft'er  less  resistance  to  the 
pressure  of  the  ovum,  and  thus  are  stretched  downward  during  each 
pain.  While,  in  contractions  of  the  uterus,  the  lower  segment  is 
thinned,  the  diminished  bulk  of  the  contracted  organ  leads  to  an 
increase  in  the  thickness  of  the  walls  of  the  body  and  fundus.* 

The  Contractions  of  the  Uterine  Ligaments. — Structurally  the  mus- 
cular fibers  of  the  round  and  broad  ligaments  are  in  direct  continuity 

with  the  external  muscular  layer  of 
the  uterus.  As  would  be  anticipated, 
they  contract  simultaneously  with  that 
organ.  In  contracting,  they  fix  the 
uterus  at  the  pelvic  brim,  while  the 
round  ligaments  serve  additionally  to 
incline  the  fundus  forward. 

The  Action  of  the  Abdominal  Mus- 
cles.— The  contraction  of  the  abdomi- 
nal walls  is  a  powerful  auxiliary  to  the 
expulsive  action  of  the  uterus.  At 
the  beginning  of  labor,  the  contrac- 
tions are  voluntary,  but,  as  labor  ad- 
vances, they  become  more  and  more 
reflex  in  character,  until,  in  many 
women,  the  disposition  to  press  dur- 
ing each  pain  assumes  the  form  of  an 
uncontrollable  impulse.  The  mechanism  by  which  these  auxiliary 
forces  are  called  into  play  is  as  follows  :  As,  toward  the  acme  of  the 
pain,  the  fundus  uteri  is  elevated  and  lifts  up  the  abdominal  walls,  the 
woman  takes  a  deep  inspiration,  the  glottis  closes,  and  the  diaphragm 
contracts.  The  latter  pushes  the  intestines  downward,  and  thus  aids 
in  raising  the  uterus  to  a  position  nearly  perpendicular  to  the  pelvic 
brim.  All  the  expiratory  muscles  then  enter  into  active  contraction. 
Meantime,  the  laboring  woman  secures  fixation  of  the  trunk  by  find- 
ing points  of  support  for  the  upper  and  lower  extremities.  By  these 
means  the  capacity  of  the  abdominal  cavity  is  greatly  diminished, 
and  the  uterus  is  compressed  not  only  by  the  adjacent  muscular  cover- 
ings, but  by  the  entire  mass  of  inclosed  viscera.    The  effect  is  twofold  : 

1.  There  results  an  augmentation  of  the  intra-uterine  pressure. 

2.  A  portion  of  the  contents  of  the  large  vessels  of  the  trunk  is 
forced  to  the  extremities.  To  this  cause  is  attributable  the  flushed, 
congested  appearance  of  the  face  during  labor-pains.    As  the  intra- 

*  For  most  of  the  following  deductions  the  writer  is  indebted  to  Dr.  Lahs's  ingenious 
work,  entitled  "  Die  Theorie  der  Geburt." 


O 

Fia.  T5.— Diagram  representing  the 
changes  in  the  thickness  of  the 
uterine  walls  during  labor.  (Lahs.) 


PHYSIOLOGY  OF  LABOR  AND  ITS  CLINICAL  PHENOMENA.  129 

abdominal  pressure  is  not  brouglit  to  bear  upon  the  organs  within  the 
pelvic  cavity,  hyperaemia  of  the  vagina  and  the  contiguous  tissues 
follows.  As  a  consequence,  the  channel  through  which  the  head  has 
to  pass,  as  labor  advances,  becomes  infiltrated  with  serum,  and  offers 
less  resistance  to  the  presenting  part.  At  the  same  time  the  glandu- 
lar structures  are  excited  to  increased  action,  and  the  lining  mucous 
membrane  becomes  lubricated  by  the  secretion  which  is  freely  poured 
out. 

The  Influence  of  the  Vagina  in  Parturition. — As  the  head  advances 
through  the  cervix,  the  vagina  at  first  opposes  an  obstacle  to  its  fur- 
ther progress.  After,  however,  the  largest  circumference  of  the  child 
has  passed  through  the  genital  canal,  the  contractions  of  the  vagina 
aid  somewhat  in  the  expulsion  of  the  after-coming  extremities  and  of 
the  placenta. 

The  Pains  of  Labor. — The  painful  sensations,  which  are  the  accom- 
paniment of  the  uterine  contractions,  begin  in  the  lower  uterine  seg- 
ment. They  are  at  first  especially  felt  over  the  sacrum,  whence  they 
radiate  to  the  rectum  and  the  bladder,  across  the  abdomen,  and  down 
the  thighs.  In  the  beginning  of  labor,  the  sensations  are  dull,  and  of 
a  bearing-down  character.  As  labor  advances,  however,  the  pains 
increase  in  acuteness,  and  in  many  persons  reach  an  unendurable  de- 
gree of  severity.  They  are  mainly  induced  through  the  compression 
of  the  uterine  nerves  by  the  contractions  of  the  muscular  fibers.  The 
severity  of  the  pains  is  consequently  proportioned  to  the  resistance 
to  be  overcome.  At  first,  as  has  been  stated,  confined  to  the  lower 
segment  of  the  uterus,  the  pains  subsequently  invade  the  body  and 
the  fundus.  The  sufferings  of  the  female  increase  with  the  mechani- 
cal distention  of  the  cervix,  especially  with  that  of  the  external  orifice, 
and  finally  reach  the  point  of  supreme  agony  as  the  head  passes 
through  the  vagina  and  vulva,  which  are  abundantly  supplied  with 
sensitive  spinal  nerves. 

Though  no  labor  is  absolutely  painless,  where  the  first  stage  is  slow 
and  the  resistance  of  the  soft  parts  slight,  the  suffering  may  become 
comparatively  insignificant. 

Influence  of  the  Pains  upon  the  Organism. — During  each  pain  the 
arterial  pressure  is  increased  ;  the  frequency  of  the  pulse  rises  until 
the  acme  is  reached,  when  it  slowly  declines  to  the  normal  point ;  the 
respirations  are  slowed  during  the  pains,  owing  to  the  contraction  of 
the  abdominal  walls,  but  are  more  rapid  in  the  pauses  as  a  consequence 
of  the  general  muscular  exertion  ;  the  temperature  rises  progressively 
during  labor,  but,  as  a  rule,  within  narrow  limits  ;  and  the  urinary 
excretion,  in  consequence  of  the  increased  arterial  pressure,  is  aug- 
mented.* 

*  Naegele,  "Lchrbuch  der  Geb.,"  p.  163. 


9 


130 


LABOR. 


The  Clikical  Couese  of  Laboe. 

Precursory  Symptoms. — About  the  thirty-ninth  week  of  pregnancy 
it  is  usual  for  the  entire  uterus  to  sink  somewhat  downward  into  the 
pelvis,  while  the  fundus  falls  forward.  This  change  of  position  is 
followed  by  considerable  relief  to  the  respiration,  and  to  previously 
existing  gastric  disturbances.  At  the  same  time  there  is  experienced 
an  increased  difficulty  in  locomotion  ;  the  oedema  of  the  lower  extremi- 
ties is  aggravated  ;  the  intra-pelvic  pressure  causes  a  frequent  desire 
to  urinate,  and  predisposes  to  the  development  of  haemorrhoids,  espe- 
cially where,  as  is  the  rule  in  primipar^e,  the  head  likewise  descends 
deep  into  the  pelvic  cavity.  Indeed,  in  primiparae  the  changes  of 
position  are  more  pronounced  than  in  women  who  have  passed  through 
repeated  pregnancies.  As  gestation  draws  to  a  close,  a  copious  glairy 
secretion  is  poured  out  from  the  cervix,  the  vagina  relaxes,  the  labia 
majora  become  swollen,  and  the  vulva  gapes  open.  For  a  variable  period 
preceding  the  advent  of  labor,  painless  contractions  occur  at  irregular 
intervals.  These  so-called  dolor es  presagiejites  are  the  ordinary  prelude 
to  labor  in  multiparae,  though  they  are  often  inappreciable  in  primi- 
parae. They  very  commonly  begin  in  the  evening  hours  and  continue 
till  toward  the  middle  of  the  night.  Very  often  they  are  associated  with 
a  dragging  sensation  between  the  sacrum  and  symphysis,  and  a  feeling 
of  tension  in  the  abdominal  region.  Sometimes  they  expand  the  os 
internum  to  a  considerable  extent,  but  never  in  such  a  way  that  any 
portion  of  the  cervical  canal  contributes  to  the  enlargement  of  the 
uterine  cavity. 

Actual  labor  has  been  divided,  as  a  matter  of  clinical  convenience, 
into  three  stages,  as  follows  : 

First  stage,  or  stage  of  dilatation  of  the  cervical  canal. 

Second  stage,  generally  termed  the  stage  of  expulsion,  comprising 
the  period  from  the  dilatation  of  the  cervix  to  the  expulsion  of  the 
child. 

Third  stage,  or  stage  of  the  placental  delivery. 

1.  The  First  Stage — Dilatation  of  the  Cervix. — The  advent  of  true 
labor  is  characterized  by  painful  contractions,  which  render  the  patient 
restless,  and  dispose  her  either  to  bend  forward  with  clinched  hands, 
or  to  seek  some  firm  support  for  the  sacrum  to  ease  her  sufferings. 
Usually,  in  the  beginning  of  labor,  women  prefer  the  sitting  posture, 
which  enables  them  to  press  with  the  forearm  against  the  sacrum  dur- 
ing the  pains.  The  pain  of  labor  begins  with  the  dilatation  of  the 
internal  os.  In  true  labor  the  dilatation  progresses  gradually.  As  the 
OS  internum  opens,  the  contractions  cause  the  membranes  to  descend 
and  press  upon  the  cervical  canal.  "With  the  advance  of  labor,  the 
pains  increase  in  intensity  and  frequency.  During  their  persistence 
the  external  os  is  j)ut  upon  the  stretch,  so  that  the  border  becomes  thin 


PHYSIOLOGY  OF  LABOR  AND  ITS  CLINICAL  PHENOMENA.  131 

and  sharply  defined.*  As  the  pain  subsides,  the  os  relaxes  and  the 
membranes  retreat.  Each  new  pain  increases  the  dilatation,  and  forces 
the  membranes  somewhat  deeper.  The  softening,  the  relaxation,  and 
the  hypersecretion  of  the  soft  parts  become  more  and  more  decided. 
As  the  borders  of  the  os  yield  to  pressure,  lacerations  form,  which 
tinge  the  mucous  discharges  with  blood.  When  the  dilatation  has 
reached  a  certain  limit  (usually  by  the  time  the  diameter  of  the  exter- 
nal OS  is  three  to  three  and  a  half  inches),  the  protruding  membranes 
remain  tense  in  the  intervals  between  the  pains,  and  are  then  ready  for 
rupture.    After  rupture,  which  usually  occurs  spontaneously,  the  water 


Fic.  7G.— Section  through  a  frozen  corpse.    Stage  of  expulsion.  (Braune.) 


in  front  of  the  child's  head  escapes,  though  the  greater  part  of  the 
amniotic  fluid  is  retained  within  the  uterus  by  the  valve-like  pressure 
of  the  presenting  part.  After  a  short  pause  the  head  descends  into  the 
cervix,  the  walls  of  which  are  stretched  to  the  pelvic  borders,  and 


132  LABOR. 

finally  become  so  far  dilated  that  cervix  and  vagina  form  one  continu- 
ous canal. 

In  case  the  presenting  part  does  not  thoroughly  tampon  the  lower 
segment  of  the  uterus,  a  more  or  less  complete  escape  of  the  entire 
amniotic  fluid  may  follow  the  rupture  of  the  membranes.  As  a  rule, 
the  tear  in  the  membranes  takes  place  in  the  most  dependent  point 
of  the  convex  portion  which  constitutes  the  bag  of  waters  in  the  cer- 
vical canal.  Sometimes,  however,  the  rupture  takes  place  above  the 
cervix,  where  there  can  be  a  gradual  escape  of  fluid  in  spite  of  the 
persistence  of  the  bag  of  waters. 

If  the  membranes  rupture  before  the  dilatation  of  the  cervix  is 


Fig.  77. — The  uterus  and  parturient  canal.    Foetus  removed.  (Braune.) 


complete,  the  head  descends  and  acts  as  a  dilating  wedge.  In  rare 
cases  the  rupture  of  the  membranes,  if  left  to  nature,  does  not  occur, 
and  the  ovum  may  descend  in  its  integrity  to  the  vulva.  In  such  in- 
stances the  membranes  sometimes  rupture  in  the  neighborhood  of  the 


PHYSIOLOGY  OF  LABOR  AND  ITS  CLINICAL  PHENOMENA.  133 


child's  neck,  and  tlie  head  is  born  coyered  with  the  so-called  ''caul/' 
i.  e.,  with  the  detached  portion  of  the  membranes,  which  old  nurses 
regard  as  significant  of  good  luck.  In  still  rarer  cases,  where  the 
foetus  is  small  and  the  amount  of  amniotic  fluid  limited,  the  entire 
ovum  may  be  expelled  without  rupture  of  its  coverings. 

2.  The  Stage  of  Expulsion. — After  the  short  pause  which  follows 
the  rupture  of  the  membranes,  the  i^ains  become  stronger  and  more 
frequent,  and  are  now  powerfully  reenforced  by  the  involuntary  con- 
tractions of  the  abdominal  muscles,  which,  though  previously  not 
entirely  inactive,  have  played  only  a  subordinate  part.  With  each 
pain  the  head  now  makes  perceptible  progress,  retreating,  however,  as 
the  pains  decline.  After  the  head  has  passed  the  pelvic  outlet,  and  is 
covered  only  by  the  soft  parts,  the  perinaeum  bulges  outward,  the  labia 
gape,  and  a  portion  of  the  head  makes  its  appearance  at  the  vulva. 
As  within  the  pelvic  canal,  with  each  pain  the  head  advances,  and  puts 
the  perinaeum  upon  the  stretch,  receding  somewhat  in  turn  as  the  pains 
subside.  The  pressure  upon  the  rectum  leads  to  the  evacuation  of 
fecal  contents.  Finally,  the  thinning  of  the  perineum  reaches  a  point 
at  which  the  sutures  can  be  readily  felt  through  its  structure ;  the  re- 
cession of  the  head  ceases  ;  the  anus  assumes  an  oval  shape  ;  the 
orifice  of  the  vulva  looks  forward  and  upward  ;  the  urethra  is  pushed 
against  the  symphysis  pubis  ;  while,  as  the  circumference  of  the  head 
in  the  neighborhood  of  the  parietal  bosses  engages  in  the  vulva,  the 
labia  and  fraenulum  form  a  thin  circular  band,  through  which,  dur- 
ing a  pain  or  the  contraction  of  the  abdominal  walls,  the  head  makes 
its  way,  usually  leaving  behind  moderate  lacerations  of  the  fraenu- 
lum or  anterior  portion  of  the  perinaeum.  The  same,  or  the  succeed- 
ing pain,  leads  then  to  the  expulsion  of  the  trunk.  Tlie  birth  of  the 
child  is  followed'  by  the  outpouring  of  the  amniotic  fluid,  which,  as 
a  rule,  escapes  colored  with  blood  from  the  site  of  the  wholly  or  par- 
tially detached  placenta. 

3.  The  Placental  Period. — The  placental  period  embraces  the  time 
from  the  birth  of  the  child  to  the  delivery  of  the  placenta  and  mem- 
branes. 

After  the  birth  of  the  child,  the  recession  of  the  blood  from  the 
brain,  which  follows  the  diminution  of  the  intra-abdominal  pressure, 
often  produces  a  sense  of  faintness,  and  sometimes  temporary  syncope. 
The  rapid  evacuation  of  the  uterus  is  at  times,  too,  succeeded  by  a  chill, 
which,  however,  does  not  betoken  the  onset  of.  fever,  but  is  the  result 
of  vaso-motor  disturbance,  and  the  loss,  through  the  expulsion  of  the 
child,  of  a  source  of  heat-supply.  Most  women,  however,  experience 
a  restful  feeling  of  comfort  and  repose.  This  sense  of  quietude  lasts 
anywhere  from  a  few  minutes  to  a  quarter  of  an  hour,  when  the  con- 
tractions return,  which  detach  the  placenta,  and  force  it  into  the  vagi- 
na.   The  separation  of  the  placenta  takes  place  in  the  meshy,  lamel- 


134 


LABOR. 


lated  layer  which  is  formed  in  the  serotina  by  the  thinned,  elongated 
walls  of  the  gland-tubules,  the  dense  cell-layer  which  forms  the  ma- 
ternal portion  remaining  adherent  to  the  placenta.  As  the  maternal 
vessels  are  necessarily  torn  across,  some  haemorrhage  follows  the  de- 
tachment. The  haemorrhage  is,  however,  speedily  arrested  by  the  con- 
tractions of  the  uterus,  which  both  compress  the  vessels  and  furnish  the 
conditions  favorable  to  the  formation  of  fibrinous  clots  in  their  distal 
extremities.  When  the  mechanism  of  expulsion  is  left  to  nature,  the 
placenta  descends  by  its  edge  into  the  vagina,  while  premature  trac- 
tions upon  the  cord  cause  it  to  present  by  its  fetal  surface  at  the  cer- 
vical orifice.  When  once  in  the  vagina,  the  expulsion  is  completed  by 
the  action  of  the  abdominal  muscles,  sustained  by  the  retraction  of  the 
muscles  which  form  the  floor  of  the  pelvis. 

According  to  Gassner,*  after  confinement  the  female  experiences, 
as  a  consequence  of  the  expulsion  of  the  ovum,  of  the  exhalations 
from  the  lungs  and  skin,  from  the  discharge  of  excrements,  and  from 
haemorrhage,  a  loss  of  weight  equivalent  to  one  ninth  of  that  of  the 
entire  body. 

Duration  of  Labor. — Spiegelberg  found,  in  506  labors,  the  average 
for  primiparae  was  17  hours,  for  multiparaB  12  hours.  In  primiparae 
past  the  thirtieth  year  Hecker  found  the  average  21  '1  hours,  while 
Ahlfeld  in  82  women  over  thirty -two  years  of  age  obtained  an  average 
of  27-6  hours,  t 

In  ordinary  normal  labor  the  second  stage  lasts  about  two  hours  in 
primiparse,  and  about  half  as  long  in  multiparas,  though  in  the  latter 
the  resistance  is  frequently  so  slight  that  a  few  pains  suffice  to  com- 
j)lete  the  delivery. 

According  to  Kleinwachter,  J  the  time  at  which  labor-pains  begin 
occurs  most  frequently  between  ten  and  twelve  o'clock  in  the  evening. 
Spiegelberg  *  states  that  the  maximum  frequency  of  births  takes  place 
between  twelve  and  three  o'clock  in  the  morning. 

The  Action  of  the  Expellent  Forces. 

Having  considered  separately  the  action  of  the  uterus,  the  uterine 
appendages,  and  the  abdominal  muscles  during  labor,  there  remains 
for  us  to  combine  these  factors  together,  and  to  show  in  what  manner 
they  contribute  to  the  end  of  all  parturient  elfort,  viz.,  the  expulsion 
of  the  ovum. 

In  the  first  place,  the  contractions  of  the  uterus  are  intermittent. 

*  Gassner,  "  Ucbcr  d.  Veranderungen  dcs  Kovpergcwiclites  b.  Schwang.,  Gebiir,  nnd 
Wochncr,"  "Monatsschr.  f.  Gcburtsk.,"  xix,  p.  18. 

f  Spiegelberg,  "Lchrbuch,"  pp.  134,  135. 

X  Kleinwachter,  "  Die  Zcit  der  Geburtsbeginnes,"  "Ztschr.  f.  Geburtsh.,"  Bd.  i,  p. 
230. 

*  Spiegelberg,  "  Lelirbucli,"  etc.,  p.  135. 


PHYSIOLOGY  OF  LABOR  AND  ITS  CLINICAL  PHENOMENA. 


135 


"When  they  lose  their  rhythmical  quality,  and  become  continuous,  they 
cease  to  belong  to  the  domain  of  physiology.  It  is  only  during  the 
act  of  contraction  that  work  is  performed.  Whenever  the  alternating 
relaxation  ceases,  and  the  uterus  passes  into  a  condition  of  tonic  con- 
traction, no  work  is  accomplished,  and  the  pains  are  inelfective. 

The  uterus  is  a  hollow  muscle,  which,  during  a  pain,  closes  down 
upon  its  contents.  If  all  parts  of  the  uterine  walls  were  of  equal  thick- 
ness, the  contractions  would  be  entirely  expended  upon  the  periphery 
of  the  ovum,  and,  as  the  contents  of  the  latter  are  practically  incom- 
pressible, the  effort  would  be  resultless.  If,  however,  the  walls  were 
so  constructed  that  the  thickness  varied  in  different  regions,  the  periph- 
eral compression  exerted  during  a  pain  would  be  followed  by  a  bulg- 
ing at  the  points  of  least  resistance,  provided  the  thinned  tissues  pos- 
sessed the  property  of  elasticity.  Now,  the  unequal  development  of  the 
uterine  walls  and  the  elasticity  of  the  uterine  tissue-elements  are  both 
anatomical  facts.  Thus,  the  fundus  and  the  lower  uterine  segment 
are  materially  thinner  than  the  intermediate  portion.  Indeed,  the 
latter  is  often  two  to  three  times  as  tliick  as  the  lower  segment.^'  As  a 
result,  therefore,  of  these  conditions  concentric  pressure  of  the  fluid 
contents  of  the  ovum  is  followed  by  an  increase  in  the  longitudinal 
diameter  of  the  uterus.  While  the  convexity  of  the  fundus  is  un- 
questionably increased  during  a  pain,  the  effect  of  the  latter  is  chiefly 
manifested  in  the  distention  of  the  lower  segment.  Various  causes 
combine  to  produce  this  result.  Near  the  cervix  the  tissues  are  not 
alone  thinner,  but  the  fibers  run  for  the  most  part  in  a  more  nearly 
longitudinal  direction,  and  therefore  offer  a  weaker  resistance  than 
that  afforded  by  the  close  interlacement  of  both  circular  and  longitu- 
dinal fibers  which  prevails  in  the  fundal  and  upper  uterine  zones. 
Then,  too,  as  was  pointed  out  by  Lahs,f  the  lower  segment  sustains, 

*  In  1870  Bandl  ("  Uebcr  das  Verhaltcn  des  Uterus  und  Cervix  in  der  Schwanger- 
schaft  und  wahrend  der  Geburt")  called  attention  to  the  thinned  condition  of  the  lower 
uterine  segment,  extending  from  what  had  previously  been  regarded  as  the  os  internum 
from  four  to  six  inches  upward,  and  terminating  abruptly  in  a  muscular  ridge  upon  the 
inner  surface.  This  ridge,  under  the  name  of  the  ring  of  Bandl,  has  been  the  subject  of 
warm  discussion.  Bandl  regards  it  as  the  true  os  internum,  and  the  thinned  lower  seg- 
ment as  the  upper  portion  of  the  cervical  canal  which  has  been  opened  by  the  growth  of 
the  ovum.  What  is  usually  regarded  as  the  anatomical  cervix,  he  insists,  is  simply  the 
lower  persistent  portion  of  the  original  canal.  This  revival  in  a  new  form  of  the  old 
Roederer  doctrine  has  been  bitterly  attacked,  and  as  hotly  defended.  The  discussion  turns 
chiefly  upon  the  true  limit  of  the  cervical  mucous  membrane,  but  upon  this  point  the 
observations  of  anatomists  are  at  wide  variance. 

For  recent  publications  in  favor  of  Bandl's  views,  vide  Kustner,  "Arch.  f.  Gynaek.," 
Bd.  xii,  II.  3 ;  Marchand  und  Bandl,  ibid.^  Bd.  xv,  H.  2.  In  favor  of  the  preservation 
of  the  cervix  during  pregnancy,  vide  Muller,  ibid.,  Bd.  xiii,  H.  1  ;  Langhans  und  MtiLLER, 
Bd.  xiv,  H.  2 ;  Sanger,  H.  3  ;  Thiede,  "  Ztschr.  f .  Geburtsh.  und  Gynack.,"  Bd.  iv,  H.  2 ; 
McDonald,  '*  Obstct.  Jour,  of  Gr.  Brit,  and  Ire.,"  July,  1811. 

f  Lahs,  "DieTheoric  der  Geburt,"  p.  116. 


136 


LABOR. 


in  the  ordinary  positions  assumed  by  the  female,  the  entire  weight  of 
the  superimposed  ovum  with  its  fluid  and  solid  contents ;  and,  finally, 
the  pressure,  transmitted  from  the  abdominal  muscles,  takes  a  direc- 
tion from  above  downward. 

So  far,  for  the  sake  of  simplicity,  we  have  regarded  the  uterus  as  a 
closed  sac,  possessing  walls  of  unequal  thickness.  In  reality  the  lower 
segment  terminates  in  an  opening,  the  canal  of  the  cervix,  which, 
though  at  the  beginning  of  labor  of  small  size,  and  offering  consider- 
able resistance  to  the  pressure  of  the  ovum,  is  capable  of  sufficient  dis- 
tention to  permit  the  exit  of  the  foetus. 

The  dilatation  of  the  cervix  is  partly  mechanical,  and  partly  the 
effect  of  certain  organic  changes  which  have  already  received  cursory 
mention. 

The  mechanical  dilatation  is  the  result  of — 1.  The  pressure  of  the 
ovum  upon  the  lower  uterine  segment,  which  forces  open  the  os  in- 
ternum, and  unfolds  the  cervix  from  above  downward. 

2.  The  retraction  of  the  uterus,  an  important  property,  which 
requires  brief  description.    While  each  contraction  of  the  uterus  is 

followed  by  relaxation,  and  a 
period  of  repose,  a  gradual 
change  is  continually  going  on 
in  the  length  and  arrangement 
of  the  muscular  fibers.  In  the 
thinned  lower  segment  the  fibers 
are  stretched,  and  separated 
from  one  another.  In  the  upper 
portion,  on  the  contrary,  they 
shorten,  and  change  their  posi- 
tion in  such  a  way  that  those 
which  previously  had  only  their 
extremities  in  contact  assume 
a  more  nearly  parallel  arrange- 
ment. The  walls,  therefore,  in 
the  upper  zones,  thicken  and 
shorten,  especially  in  the  lon- 
gitudinal direction.  The  limit 
between  the  thinned  lower  seg- 
ment and  the  upper  thickened 
zones  is  marked  by  a  distinct 
ridge  termed  the  ring  of  Bandl. 
It  is  to  the  changes  in  the  ute- 
rus which  take  place  above  the 
ring  of  Bandl  that  the  term  re- 
traction is  applicable.  As  the  retraction  is  progressive,  it  leads  to  a 
gradual  withdrawal  upward  of  the  uterine  walls,  in  consequence  of 


Fig 


Lonixitudinal  section  through  walls  cf 
■     ■ (Bandl). 

OS  extcr- 


uterus  in  eiirhtli  month  of  pregnane 
a,  ring  of  Bandl ;  os  internum  ;  ci 
num. 


PHYSIOLOGY  OF  LABOR  AND  ITS  CLINICAL  PHENOMENA.  137 


which  the  lower  segment  is  not  only  put  npon  the  stretch  during  tlie 
pains,  but,  toward  the  end  of  the  period  of  dilatation,  is  subjected  to 
a  greater  or  less  degree  of  permanent  tension.  Then,  too,  as  the  ring 
of  Bandl  moves  upward,  the  longitudinal  fibers  of  the  lower  segment, 
by  reason  of  their  insertion  in  part  at  least  into  the  vaginal  portion, 
exert  a  direct  influence  in  dilating  the  cervical  canal. 

3.  When  the  abdominal  muscles  contract,  the  uterus  is  pressed 
downward  into  the  pelvic  cavity.  The  descent  is,  however,  limited 
by  the  attachment  of  the  uterine  ligaments,  and  the  adjacent  organs. 
But  the  resistance  afforded  by  the  uterine  attachments  exercises  a  pe- 
ripheral traction  upon  the  cervix,  and  thus  tends  to  draw  its  walls 
asunder. 

The  normal  dilatation  of  the  cervix  is,  however,  by  no  means  a 
matter  of  pure  mechanical  distention.  If  the  canal  which  forms  the 
communication  between  the  vagina  and  the  uterus  were  simj^ly  an  elas- 
tic tube,  it  would  of  necessity  retract  down  upon  the  neck  of  the  foetus 
after  the  passage  of  the  head,  and  thus  a  new  distention  would  be 
required  to  permit  the  passage  of  the  shoulders.  Indeed,  the  condi- 
tions of  an  elastic  tube  are  not  unfrequently  realized  in  versions, 
where  an  attempt  is  made  to  extract  the  foetus  through  an  im- 
perfectly dilated  os  ;  in  which  case,  after  the  disengagement  of  the 
shoulders,  the  cervix  is  apt  to  close  upon  the  neck,  and  arrest  the 
delivery  of  the  after-coming  head.  That  this  complication  does  not 
happen  as  a  rule  is  due  to  the  fact  that  in  natural  labors  the  me- 
chanical expansion  is  associated  with  certain  organic  changes  which 
render  the  cervix  soft  and  distensible,  and  at  the  same  time  diminish 
its  retractility.  The  basis  of  the  organic  changes  consists  in  the  serous 
infiltration  of  the  lymphatic  interspaces,  which  separates  the  tissue- 
elements,  and  deprives  them  of  the  resistance  afforded  by  the  force  of 
cohesion.  The  main  factor  in  the  production  of  the  softening  of  the 
cervix  is  an  active  hyperaemia,  which  the  cervix  shares  during  preg- 
nancy with  all  the  pelvic  organs,  and  which  during  labor  is  greatly 
enhanced  by  the  diminished  pressure  to  which  the  parts  below  the 
pelvic  brim  are  subjected.  We  have  already  noticed  how,  during  the 
acme  of  a  pain,  the  contents  of  the  uterine  vessels  are  forced  into  the 
vessels  of  the  intra-pelvic  viscera. 

In  normal  head  presentations  the  organic  changes  are  in  a  special 
degree  furthered  by  the  formation  of  what  is  known  as  the  bag  of 
waters.  As  the  head  descends  into  the  lower  uterine  segment,  the 
contraction  of  the  muscular  fibers  around  its  largest  circumference 
separates  a  layer  of  fluid  from  the  contents  of  the  uterine  cavity.  At 
first  this  layer  becomes  tense  only  during  a  pain.  With  the  descent 
of  the  head  the  tension  increases,  and  the  \'  bag  of  waters  "  is  formed. 
As  the  abdominal  pressure  is  not  operative  below  the  pelvic  line,  and 
as  the  intra-uterinc  pressure  is  arrested  in  a  measure  by  the  child's 


138 


LABOR. 


head,  in  tliat  portion  of  the  uterus  which  lies  below  the  circle  of 
cephalic  compression,  hyperaemia,  serous  infiltration,  and  softening  fol- 
low as  necessary  corollaries  of  the  anatomical  conditions.  The  value 
of  the  bag  of  waters  in  dilating  the  cervix  is  due,  therefore,  not  only 
to  the  hydrostatic  pressure  it  exerts,  but  to  the  manner  in  which  it 
favors  the  development  of  the  organic  processes  described. 

Thus  far  we  have  considered  the  expellent  forces  as  acting  upon 
the  ovum  as  a  whole.  Many  authorities  accept  in  addition  a  direct 
pressure  of  the  fundus  upon  the  breech  of  the  child,  which  is  transmit- 
ted through  the  spinal  column  to  the  cej^halic  pole.  A  little  reflec- 
tion, however,  will  show,  as  Lahs  *  has  pointed  out,  that  so  long  as  the 
ovum  contains  any  measurable  quantity  of  fluid,  or  at  least  more  than 
enough  to  fill  the  fetal  interspaces,  the  immediate  contact  of  the 
breech  with  the  fundus  is  hardly  possible.  To  be  sure,  Ahlfeld  f  de- 
termined, by  direct  measurements,  that  there  was  an  actual  increase  of 
about  one  and  a  half  inch  in  the  distance  between  the  two  poles  of 
the  child  in  head-presentations  during  the  height  of  a  pain.  Schroe- 
der  J:  attributes  this  extension  to  the  lateral  compression  of  the  foetus, 
which  results  from  the  diminution  of  the  transverse  diameter  of  the 
uterus  during  contraction  ;  but  it  is  evident  that  lateral  pressure  would 
equally  produce  an  elevation  of  the  fluid  contents  of  the  ovum,  and 
thus,  as  the  fundus  assumes  a  spherical  shape,  prevent  the  impinge- 
ment of  the  breech.  Moreover,  it  is  not  easy  to  see  how,  so  long  as 
the  foetus  is  surrounded  by  a  fluid  medium,  any  effective  propulsive 
force  can  be  transmitted  through  a  flexible  column  like  the  spine.  It 
is  certain  that,  in  the  intervals  of  the  pains,  manual  pressure  upon  the 
breech  through  the  fundus  simply  bends  the  fetal  body,  and  deflects 
it  from  the  vertical  direction.  Even  if  during  a  pain  the  lessening 
of  the  uterus  in  the  transverse  diameter  hinders  this  movement  to 
some  extent,  the  increase  antero-posteriorly  would  still  leave  ample 
space  for  lateral  incurvation. 

The  descent  of  the  ovum  is  followed  necessarily  by  increased  ten- 
sion of  the  bag  of  waters.  Under  a  pressure,  estimated  by  Duncan  * 
as  varying,  according  to  the  resistance  of  the  membranes,  between 
four  II  and  thirty-seven  and  a  half  pounds,  rupture  occurs.  The  cervix 
then  usually  closes,  but  remains  dilatable  ;  i.  e.,  it  yields  readily  to 
pressure,  and  offers  no  resistance  to  the  advancing  head. 

The  pressure  exerted  by  the  united  action  of  the  uterine  and  ab- 
dominal walls  requisite  to  accomplish  delivery,  according  to  the  esti- 

*  Laiis,  "Studicn  zur  Geburtskuudc,"  "Arch.  f.  G}Miaek.,"  Bd.  iii,  p.  195. 

f  AiiLFELD,  "Arch.  f.  Gynaek.,"  Bd.  ii,  p.  367. 

:};  SciiROEDER,  "  Lehrbuch  dcr  Geburtsliiilfe,"  Cte  Aufl.,  p.  15G. 

^  Duncan,  "  Ilesearchcs  in  Obstetrics." 

II  KiBEMONT,  "Recherches  experimcntales  sur  la  resistance,  etc.,  des  membranes  de 
I'oeuf  humain,"  p.  35,  places  the  minimum  resistance  at  fifteen  and  three  fourths  pounds. 


MECHANISM  OF  LABOR. 


139 


mates  of  Scliatz,*  based  upon  manometric  observations,  varies  between 
seventeen  and  fifty-five  pounds,  f  Although  the  methods  by  which 
both  the  results  of  Schatz  and  Duncan  have  been  obtained  possess 
defects,  w^hich  the  authors  themselves  make  no  attempts  to  conceal, 
they  are  quoted  as  furnishing  approximations  to  the  truth. 


CHAPTER  VIII. 

MECHANISM  OF  LABOR. 

Anatomical  factors. —  Anatomy  of  pelvis. —  Sacrum. —  Coccyx. —  Ossa  innominata. — 
The  ilia.— The  pubes. — The  ischia. — Articulations  of  the  pelvis. — Sacro-iliac  articu- 
lations.— Symphysis  pubis. — The  pelvic  ligaments. — Obturator  membrane. — Sacro- 
sciatic  ligaments. — Inclination  of  the  pelvis. — The  pelvis  as  a  whole. — The  pelvic 
planes. — Plane  of  the  brim. — Plane  of  the  outlet. — Planes  of  the  cavity. — Ischial 
planes. — Pelvic  axis. — Differences  between  male  and  female  pelvis. — Differences  be- 
tween the  infantile  and  adult  pelvis, — The  soft  parts  of  the  pelvis. — The  perineal 
floor. — The  head  of  the  foetus  at  term. — Sutures  and  fontanelles. — The  diameters  of 
the  fetal  head. — The  articulation  of  the  head  with  the  spinal  column. 

The  mechanism  of  labor  comprehends  the  movements  of  adjust- 
ment, by  means  of  which  the  foetus  accommodates  itself  to  the  dimen- 
sions of  the  bony  pelvis  and  to  the  variations  in  the  direction  of  the 
parturient  canal.  Its  study  is,  therefore,  properly  prefaced  by  the 
enumeration  of  a  series  of  anatomical  details  relating  to  the  pelvic 
ring  and  the  soft  tissues  which  form  the  floor  of  the  pelvic  basin,  and 
to  the  structure,  the  diameters,  and  the  reductibility  of  the  fetal  head. 

The  Ai^ATOMY  of  the  Pelvis. 

The  following  description  includes  only  such  points  as  are  of  direct 
obstetrical  interest : 

The  bony  pelvis  is  formed  by  the  union  of  the  sacrum  and  coccyx 
and  the  two  ossa  innominata. 

The  Sacrum. — The  sacrum  is  a  curved  quadrilateral  bone,  inserted 
like  a  wedge  between  the  ossa  innominata.  Like  a  wedge,  it  is  broad 
above  and  tapers  toward  its  lower  extremity.  It  is  composed  of  a 
central  vertebral  portion,  and  two  outer  masses  termed  the  alse  or  wings. 
The  central  portion,  as  its  name  implies,  is  really  a  continuation  of 
the  spinal  column.  In  early  childhood  it  consists  of  five  distinct  ver- 
tebrae with  well-defined  joint-surfaces  and  intermediate  cartilaginous 
disks  ;  but,  with  the  completion  of  the  growth,  the  whole  becomes  con- 
solidated into  a  single  piece  by  the  inter-articular  deposition  of  bone. 

*  Vide  ScHROEDER,  "Lehrbuch,"  6te  Aufl.,  p.  158. 

f  PoLAiLLON,  "Recherches  sur  la  physiologic  dc  I'utcrus  gravide,"  p.  38,  estimates 
the  minimum  pressure  at  twenty-three  pounds. 


140 


LABOR. 


The  bony  union  is  confined  chiefly  to  the  outer  circumference,  and  is 
marked  by  ridges  termed  the  linece  transversm.  The  base  of  the 
sacrum  articulates  Avith  the  last  lumbar  vertebra,  with  which  it  forms 
a  projecting  angle.  It  possesses  a  convex  anterior  surface,  termed  the 
promontory,  which  juts  forward  and  encroaches  upon  the  pelvic  space. 

From  the  sides  of  the  central  piece  there  extend  two  triangular 
portions  of  bone,  termed  the  alse  or  wings.  Under  normal  conditions 
they  are  symmetrical.  They  are  developed  upon  each  side  from  three 
independent  nuclei,  which  make  their  appearance  near  the  bodies  of 
the  three  upper  vertebrae.  They  are  supposed  to  have  the  morphological 
significance  of  ribs.  In  the  course  of  this  growth  they  fuse  together, 
except  at  the  points  of  junction  of  the  bodies  of  the  vertebrae,  where 
they  have  between  them  open  spaces  or  foramina,  for  the  passage  of 
the  spinal  nerves. 

The  sacrum  in  the  female  is  about  four  and  a  half  inches  wide,  and 
from  four  to  four  and  a  half  inches  long,  when  measured  from  the  pro- 
montory to  the  lower  extremity.    The  sacrum  possesses  two  curves  : 


Fig.  79.— Sacrum  and  coccyx  (anterior  surface). 


one,  less  marked,  from  side  to  side,  and  the  other  extending  from  above 
downward.  The  depth  of  the  latter  is  greatest  just  below  the  upper 
border  of  the  third  vertebra,  where  it  measures  a  little  over  an  inch. 

Upon  the  posterior  surface  we  notice  a  canal,  continuous  with  the 
spinal  canal,  which  runs  the  entire  length  of  the  sacrum,  but  is  incom- 
pletely closed  at  the  fifth  vertebra,  giving  rise  to  a  slit-like  opening, 
termed  the  Jiiatus  sacraHs.  In  the  middle  line  the  spinous  processes 
coalesce  into  a  vertical  crest  for  the  attachment  of  the  erector  spinas 
muscle.  The  posterior  lateral  masses  are  formed  by  the  fusion  of  the 
transverse  processes,  and  their  consolidation  with  the  anterior  struct- 
ures.    Next  to  the  vertebrae,  however,  spaces  are  left  between  the 


MECHANISM  OF  LABOR. 


141 


processes  for  the  passage  of  the  posterior  sacral  nerves.    Opposite  the 
three  upper  vertebrae,  the  outer  border  is  known  as  the  tuberosity  of 
the  sacrum.    It  possesses  a  roughened  surface,  to 
which  are  attached  the  sacro-iliac  ligaments. 

The  upper  portion  of  the  side  of  the  sacrum 
is  furnished  with  an  ear-shaped  articulating  sur- 
face termed  the  siiperfioies  auriciilaris. 

The  Coccyx. — The  coccyx  is  composed  of  four 
rudimentary  vertebrae,  which  progressively  dimin- 
ish in  size  from  above  downward.  It  possesses  as 
a  whole,  therefore,  a  triangular  shape.  It  is  at- 
tached to  the  extremity  of  the  sacrum  by  a  hinge- 
joint,  and  is  pushed  backward  during  defecation, 
and  in  childbirth  as  the  head  passes  the  pelvic 
outlet.  It  is  only  when  anchylosed  that  the 
coccvx  assumes  obstetrical  importance. 

r^-,     r\       T  •     ±.        T-i    1         •  •     /        FiG'  80. — Section  of  sacrum 

ine  Ossa  Innommata. — J^ach  os  mnommatum  and  coccyx, 
may  be  roughly  compared  to  a  figure  eight,  of 
which  the  upper  and  larger  portion  slants  upward,  outward,  and  back- 
ward, while  the  lower  smaller  division  inclines  downward  and  inward. 
IJp  to  the  age  of  puberty  it  consists  really  of  three  bones,  which  are 
connected  at  the  acetabulum  by  cartilage  of  a  Y-shape.  These  three 
bones  are  termed  respectively  the  ilium,  the  ischium,  and  the  pubes, 
names  which  are  subsequently  retained  for  convenience  of  description, 
in  spite  of  the  fact  that  in  adult  life  the  separate  parts  become  solidly 
united,  by  the  deposition  of  bone-tissue,  into  a  single  continuous  piece. 


Fio.  81. — Os  innominatum,  before  consolidation.    1,  ilium  ;  2,  ischium  ;  3,  pubes. 

The  iliac  portion  has  an  external  surface  marked  by  a  number  of 
roughened  lines,  to  which  are  attached  the  three  gluteal  muscles.  The 
inner  surface  is  excavated  and  forms  the  so-called  iliac  fossa,  which 


142 


LABOR. 


contains  the  internal  iliac  muscle.  The  fossa  is  bounded  below  by  the 
linea  arcuata  interna,  a  convex  ridge  which  contributes  to  form  the 
brim  of  the  pelvis.  The  upper  border  or  crest  of  the  ilium  possesses 
an  S-shaped  curve,  the  anterior  extremities  of  which  are  directed  in- 
ward. The  crest  of  the  ilium  terminates,  front  and  rear,  in  bony 
prominences,  termed  respectively  the  anterior  and  posterior  superior 
spinous  processes.  Beneath  the  upper  spines,  and  separated  from  them 
by  curved  indentations,  are  Uyo  lower,  less  sharply  defined  projections, 
termed  the  anterior  and  posterior  inferior  spinous  processes.  Behind 
the  iliac  fossa  is  situated  an  ear-shaped  articular  surface,  the  super- 
ficies auricularis,  which  corresponds  to  the  surface  of  similar  name 
described  upon  the  sides  of  the  sacrum. 


The  pubic  portion  consists  of  the  body  and  two  rami.  The  body 
presents  upon  its  inner  border  an  oval  surface,  which  articulates  with 
the  pubic  bone  upon  the  opposite  side.  The  superior  border  is  fur- 
nished with  a  rough  crest,  terminating  in  the  projecting  spine.  The 
upper,  or,  as  it  is  usually  designated,  the  horizontal  ramus,  possesses 
a  ridge,  the  pecten  pubis,  extending  from  the  spine  and  becoming  con- 
tinuous with  tlie  linea  arcuata  of  the  ilium.  The  linea  terminalis,  or 
boundary-line  of  the  pelvic  brim,  is  generally  known  as  the  ilio-pec- 
tineal  line,  from  its  sources  of  origin.    Near  the  junction  of  the  ilium 


MECHANISM  OF  LABOR. 


143 


and  03  pubis  is  situated  a  slight  elevation^  the  ilio-pectineal  eminence, 
which,  however,  according  to  Luschka,*  belongs  entirely  to  the  pubic 


ORESr. 


Fig.  83. — Inner  surface  of  os  innominatum. 

bone.  The  descending  ramus  helps  to  bound  the  obturator  foramen, 
and  to  form  the  pubic  arch.  The  ischium  completes  the  lower  portion 
of  the  OS  innominatum.  It  consists  of  two  rami,  which,  with  the  rami 
of  the  pubic  bones,  include  the  obturator  foramen.  It  contributes  about 
two  fifths  to  the  formation  of  the  acetabulum  ;  from  this  the  descend- 
ing ramus  drops  vertically  downward,  and  thence  curves  forward,  and 
forms  the  ascending  ramus,  which  unites  with  the  descending  ramus 
of  the  pubes.  At  the  point  where  the  descending  ramus  hooks  forward 
there  is  a  thickened  projection,  termed  the  tuberosity  of  the  ischium, 
upon  which  the  body  rests  in  the  sitting  posture.  Upon  the  posterior 
border  of  the  descending  ramus  there  is  a  sharp  spine,  projecting 
inward,  which  plays  an  important  part  in  the  mechanism  of  labor. 
Between  the  posterior  inferior  spinous  process  and  the  spine  of  the 
ischium  there  is  a  deep  incurvation,  termed  the  great  sciatic  notch  ; 
while  a  smaller  incurvation,  between  the  spine  and  the  tuberosity,  is 
known  as  the  small  sciatic  notch. 

The  Pelvic  Articulations. — The  articulations  of  the  ossa  innominata 
with  the  sacrum  are  usually  termed  the  sacro-iliac  synchondroses.  The 
anterior  articulation  of  the  innominate  bones  with  one  another  is  known 
as  the  symphysis  pubis. 

^  *  LuscHKA,  "Die  Anatomie  des  menschlichen  Bcckens,"  p.  86. 


144  LABOR. 

Tlie  term  synchondrosis/'  as  applied  to  the  sacro-iliac  articulation, 
is  really  a  misnomer.  Luschka  has  shown  that,  in  place  of  an  inter- 
vening plate  of  cartilage,  section  demonstrates  the  existence  of  a  true 


Fig.  84.— Section  through  the  left  sacro-iliac  articulation  (natural  size).  (Luschka.) 

synovial  membrane,  limiting  a  narrow  but  well-defined  joint-cavity. 
The  middle  third  of  the  iliac  surface  is  convex,  and  fits  into  a  corre- 
sponding concave  depression  on  the  sacral  end.    There  is  likewise  a 


Fig.  85. — Section  of  symphysis.  (Luschka.) 


^*bite"  or  ledge  in  front,  formed  by  the  ilium,  which  aids  in  prevent- 
ing the  sacrum  from  slipping  forward  into  the  pelvic  cavity. 

The  office  of  maintaining  the  sacrum  in  position  devolves  chiefly 


MECHANISM  OF  LABOR. 


145 


upon  the  ligaments  distributed  front  and  rear,  and  particularly  upon 
the  very  numerous  and  closely  interwoven  bundles  extending  from  the 
tuberosities  of  the  sacrum  to  the  roughened  portions,  or  tuberosities, 
of  the  ilia,  which  project  posteriorly  beyond  the  articulation. 

The  symphysis  pubis  is  likewise  supplied  with  a  small  cavity,  only 
the  posterior  portion  of  which  possesses  a  synovial  membrane.  The 
fibro-cartilage  between  the  articulating  surfaces  of  the  bones  is  thicker 
in  front  than  behind.  The  anterior  ligaments  are  more  developed  than 
the  posterior  ones,  and  allow  no  movements  of  importance  to  take 
place  in  the  non-pregnant  condition. 

The  Pelvic  Ligaments. — In  addition  to  the  ligaments  which  have 
already  been  noticed  as  contributing  to  the  solidity  of  the  joints,  the 


Fig.  86. — Front  view  of  pelvis,  with  ligaments.  (Quain.) 


following  help  to  close  in  the  pelvis.  Across  the  obturator  foramen  is 
stretched  a  fibrous  septum,  comjolete  except  where  a  smail  opening  is 
left  for  the  passage  of  the  nerve  and  vessels. 

The  great  sacro-sciatic  ligament  extends  partly  from  the  lower  bor- 
der of  the  sacro-iliac  articulation,  and  partly  from  the  lower  border  of 
the  sacrum  and  coccyx  to  the  tuberosity  of  the  ischium.  The  small 
sacro-sciatic  ligament  lies  in  front  of  the  preceding,  and  extends  from 
the  side  of  the  sacrum  and  coccyx  to  the  spinous  process  of  the 
ischium.  These  two  ligaments  close  the  large  and  small  sacro-sciatic 
notches,  and  convert  them  into  two  foramina,  which  bear  the  same 
name. 

The  Inclination  of  the  Pelvis.— The  plane  of  the  brim  of  the  pelvis 
was  formerly  supposed  to  run  nearly  parallel  to  the  horizon,  whence 
10 


146  LABOR. 

the  term  ^Hiorizontal  ramus,"  applied  to  the  upper  branch  of  the 
pubes.    As  a  fact,  however,  in  the  upright  position,  the  inclination  of 


Fig.  87. — Transverse  section  through  pelvis,  to  show  the  sacro-sciatic  ligaments.  (Tamier 

et  Chantreuil.) 


the  brim  to  the  horizon  varies  from  45°  to  100°.  According  to  Meyer, 
the  center  of  gravity,  instead  of  passing  directly  through  the  median 
line  of  the  acetabula,  is  situated  somewhat  posteriorly,  so  that  a  tilting 


Fig.  88. — Section  showing  the  inclination  of  the  pelvis  according  to  Naegele.    (Tamier  et 

Cliantrcuil.) 


MECHANISM  OF  LABOR. 


147 


of  the  pelvis  backward  is  only  prevented  by  the  strong  ilio-femoral 
ligaments  (Fig.  86).  Whatever,  therefore,  serves  to  relax  the  ligaments 
in  question  diminishes  the  angle  of  inclination,  while  positions  that 
increase  the  natural  tension  cause  the  pelvis  to  assume  a  nearly  vertical 
attitude.  Experimentally  Meyer  found  that  the  pelvic  inclination  was 
diminished  to  the  greatest  extent  when  the  thighs  were  moderately 
separated  and  rotated  slightly  inward,  while  its  increase  was  due  to  four 
conditions  :  closing  the  knees,  stretching  the  legs  widely  apart,  exter- 
nal rotation,  and  exaggerated  internal  rotation.  Naegele  endeavored 
to  ascertain  the  normal  inclination  upon  the  living 'subject,  by  deter- 
mining the  distance  between  the  extremity  of  the  coccyx  and  an  hori- 
zontal line  drawn  from  the  lower  border  of  the  symphysis,  and  then 
placing  the  bony  pelvis  in  a  position  conforming  to  the  measurement 
thus  obtained.  He  found  in  this  way  the  mean  inclination  was  nearly 
60°,  a  result  explained  by  the  fact  that  the  method  of  measurement 
rendered  a  separation  of  the  knees,  and  consequently  an  increase  of 
tension  of  the  ilio-femoral  ligaments,  a  matter  of  necessity.* 

Movements  at  the  Pelvic  Aeticulations. 

At  the  symphysis  pubis  during  gestation  the  fibers  which  compose 
its  fibro-cartilage  become  infiltrated  with  serum,  and  the  ligaments 
elongate,  so  that  at  term  the  distance  between  the  articular  surfaces  of 
the  pubic  bones  is  increased  twofold.  Budin  has  shown  that  if  the 
patient,  when  the  finger  is  introduced  into  the  vagina,  and  pressed 
upward  against  the  lower  border  of  the  symphysis,  be  made  to  walk, 
an  elevation  of  the  ramus  upon  the  side  of  the  extremity  in  motion 
can  be  distinctly  recognized.  In  the  rule,  this  mobility  is  most 
marked  in  women  who  have  borne  a  number  of  children,  f 

Zaglass  first  pointed  out  that,  in  spite  of  the  close  union  at  the 
sacro-iliac  articulation,  a  certain  degree  of  mobility  between  the  sacrum 
and  iliac  bones  existed.  Thus,  in  defecation,  when  the  body  is  thrown 
forward,  the  promontory  is  tilted  toward  the  symphysis,  and  the  in- 
ferior extremity  of  the  sacrum  is  thrown  backward,  thereby  enlarging 
the  outlet  of  the  pelvis.  Matthews  Duncan  describes  similar  move- 
ments, only  exaggerated  in  extent,  during  pregnancy,  and  points  out 
how  they  practically  contribute  to  facilitate  labor.  Thus,  at  the  be- 
ginning of  labor,  as  the  head  enters  the  brim,  the  woman  naturally 
chooses  to  sit  up,  to  walk  about,  or,  if  in  bed,  to  recline  with  the 
lower  extremities  extended,  positions  which  favor  the  rotation  back- 
ward of  the  upper  portion  of  the  sacrum,  and  the  consequent  increase 
of  the  antero-posterior  diameter  at  the  superior  strait.  As  the  head, 
however,  descends  to  the  floor  of  the  pelvis,  the  patient  instinctively 

*  ScHROEDER,  "  Lehrbuch  der  Geburtshulfe,"  6te  Aufl.,  note,  p.  7  ;  Naegele,  8te  Aufl., 
p.  31. 

f  Tarnier  et  Chantreuil,  "  Traite  de  I'art  dcs  accouchcments,"  p.  239. 


148 


LABOR. 


Fig.  89. — Diagram    showing  oscillatory 
movements  of  sacrum.  (Duncan.) 


draws  up  her  knees,  throws  the  body  forward,  and  during  a  pain 
contracts  the  abdominal  muscles.  In  this  way  she  succeeds  in  tilting 
up  the  pubes,  in  pressing  the  promontory  forward,  and  in  rotating 

the  point  of  the  sacrum  backward, 
so  as  to  perceptibly  increase  the  con  - 
jugate diameter  at  the  pelvic  outlet. 

The  Pelvis  as  a  Whole.— The 
pelvis  is  divided  by  the  linea  termi- 
nalis  into  an  upper  and  lower  por- 
tion. 

The  upper,  or,  as  it  is  usually 
termed,  the  large  pelvis,  is  composed 
of  the  lumbar  vertebrae  and  the  up- 
per surfaces  of  the  wings  of  the  sa- 
crum behind,  the  spreading  portions 
of  the  ilia  upon  the  sides,  while  the 
anterior  segment  is  closed  in  by  the 
muscles  of  the  abdominal  parietes. 
In  shape,  the  bony  part  of  the  large  pelvis  has  been  compared  to  the 
rim  of  a  barber's  basin.  Obstetrically  the  iliac  fossae  are  of  interest, 
inasmuch  as  they  furnish 
shelves  upon  which  the  head 
of  the  foetus  in  multiparae 
commonly  rests  during  the 
latter  part  of  pregnancy.  The 
inclination  of  the  ilia  to  the 
horizon,  the  shape  of  the 
crests,  and  the  distance  be- 
tween them,  together  with 
the  distance  between  the  two 
anterior  superior  spinous  pro- 
cesses, are  important  points 
for  study,  because  they  fur- 
nish data  upon  which  valu- 
able inferences  are  based  in  cases  of  pelvic  deformity,  relative  to  the 
shape  and  dimensions  of  the  pelvic  canal. 

It  will  be  remembered  that  the  crests  of  the  ilia  possess  an  S-shaped 
curve.  Normally,  the  widest  distances  between  the  crests  measure  ten 
inches  ;  the  distance  between  the  anterior  superior  spinous  processes 
measures  nine  inches.  *  The  slope  of  the  inner  surfaces  of  the  ilia  is  such 
that  an  extension  of  the  lines  drawn  from  the  crest  to  the  linea  tcrmi- 
nalis  would  meet  in  the  neighborhood  of  the  fourth  sacral  vertebra. 


Fig.  90. — Anterior  half  of  the  pelvis. 


*  As  no  two  pelves  possess  precisely  the  same  dimensions,  pelvic  measurements  arc 
given  somewhat  differently  by  authors.  They  arc  obtained  cither  by  taking  the  mean  of 
a  large  number  of  pelves  (a  method  which  furnishes  fractions  difficult  to  remember,  but 


MECHANISM  OF  LABOR. 


149 


The  inferior  or  small  pelvis  comprises  the  portion  below  the  linea 
terminalis.  It  is  formed  by  the  sacrum,  the  coccyx,  the  lower  por- 
tion of  the  ilia,  the  ischia  and  pubes,  the  obturator  membrane,  and 
the  sacro-sciatic  ligaments.  Together  the  foregoing  inclose  a  basin- 
like cavity,  which,  though  open  below  in  the  skeleton,  is  closed  in 
by  soft  parts  in  the  living  subject.  The  posterior  wall,  formed  by 
the  sacrum  and  coccyx,  measures  five  inches  in  a  direct  line  from  the 
promontory  to  the  apex  ;  the  anterior  w^all  at  the  symphysis  pubis  mea- 
sures one  and  three  quarters  inch;  the  lateral  walls,  from  the  linea  ter- 
minalis to  the  tuberosities  of  the  ischia,  measure  three  and  three  quar- 
ters inches.  The  posterior  wall  is  curved  ;  the  symphysis  pubis  slopes 
downward  and  inw^ard,  so  as 

to  run  nearly  parallel  with  ■^'^^^^'^^^^^ 


soft  structures  and  the  sacro- 
sciatic  ligaments.    The  transverse  diameter,  owing  to  the  incline  of 
the  side-w^alls,  narrows  toward  the  outlet. 

The  Planes  and  Axes  of  the  Pelvis.— The  eccentric  forms  of  the 
pelvic  bones  render  it  extremely  difficult  to  convey  a  clear  impression 
of  the  nature  of  the  pelvic  inclosure.  As  a  means  to  this  end  it  is 
customary  to  study  a  series  of  planes  drawn  at  different  levels  through 
the  pelvic  w^alls,  which  serve  to  show  the  changes  in  the  shape  and 
dimensions  of  the  bony  canal  at  selected  points  of  observation.  By  a 
plane  is  meant  simply  a  mathematical  surface,  without  reference  to 
depth  or  thickness. 

The  upper  and  lower  openings  are  both  somewhat  contracted,  and 
hence  are  termed  respectively  the  superior  and  inferior  straits,  while 
the  space  between  is  denominated  the  cavity  of  the  pelvis. 

The  first  plane  requiring  our  attention  is  that  of  the  superior  strait 
or  brim.  It  is  bounded  by  the  linea  terminalis,  and  has  an  elliptical 
contour,  with  a  depression  posteriorly,  produced  by  the  projection 
of  the  promontory  of  the  sacrum. 

offering  no  special  advanta^'^cs  in  the  way  of  accuracy),  or  by  selecting  as  the  normal  stand- 
ard either  a  whole  number,  or,  where  fractions  are  necessary,  the  nearest  half  or  quarter 
approximating  to  the  mean  average.  The  latter  plan  recommends  itself  in  practice  equally 
on  the  score  of  utility  and  convenience. 


the  two  upper  sacral  vertebrae  ; 
the  rami  of  the  pubes  approach 
one  another  at  an  angle  of  95° 
to  100°  and  unite  beneath  the 
symphysis  in  the  form  of  an 
arch,  the  arcus  pubis  ;  the  side- 
walls  are  solid  in  front  where 
they  are  constituted  by  the 
ischia,  while  behind  the  great 
sciatic  notch  is  closed  only  by 


Fig.  91. — Posterior  half  of  the  pelvis. 


150 


LABOR. 


The  dimensions  of  eacli  plane  are  determined  by  measuring  the 
antero-posterior,  the  transverse,  and  the  two  oblique  diameters. 


DISTANnE  BETWEEN 
THE  CRESTS  lOIM. 


OBLIQUE  DIAMETER  SIN. 


conjugate  4  '/+  im. 
Fig.  92. 


The  antero-posterior,  or,  as  it  is  generally  termed,  the  conjugate 
diameter,  extends  from  the  upper  border  of  the  symphysis  pubis  to  the 
promontory.  Its  length  is  four  and  a  quarter  inches.  About  two 
fifths  of  an  inch  below  the  upper  border  of  the  symphysis  is  situated 
the  obstetrical,  as  distinguished  from  the  anatomical,  conjugate.  The 
length  of  the  former,  owing  to  the  thickening  of  the  pubic  bones,  is 
reduced  to  four  inches. 

The  transverse,  sometimes  termed  the  bis-iliac,  diameter  is  the 
widest  distance  between  the  ilia.  It  measures  five  and  a  quarter 
inches. 

The  oblique  diameters  extend  from  the  ilio-pectineal  eminences  to 
the  opposite  sacro-iliac  articulations.  The  distance  between  the  points 

mentioned  is  five  inches. 
The  right  oblique  diameter  is 
the  one  directed  to  the  right 
acetabulum,  and  the  left  to 
the  left  acetabulum. 

The  axis  of  the  superior 
strait  is  represented  by  a  line 
drawn  perpendicular  to  the 
center  of  the  plane.  The 
extension  of  this  line  falls 
below  upon  the  extremity  of 
the  coccyx,  and  above  strikes 
the  abdomen  near  the  umbil- 
icus {vide  Fig.  94).  The  circumference  of  the  brim  is  very  nearly 
sixteen  inches. 

The  inferior  strait  proper,  or  outlet  of  the  pelvis,  is  bounded  by 
the  sub-pubic  ligament,  the  pubic  rami,  the  rami  and  tuberosities  of 
the  ischia,  the  sciatic  ligaments,  and  the  coccyx.    Owing  to  the  pro- 


MECHANISM  OF  LABOR. 


151 


jection  of  the  ischia,  the  surface  of  tlie  pelvic  outlet  is  rendered  con- 
vex, or,  perhaps,  is  better  described  by  supposing  it  to  be  composed 
of  two  obtuse-angled  triangles  with  apices  at  the  symphysis  and  coccyx, 
and  with  a  common  base  formed  by  a  line  drawn  through  the  ischia. 

The  antero-posterior  diameter  extends  from  the  lower  border  of 
the  symphysis  to  the  extremity  of  the  coccyx.  It  measures  three  and 
three  quarters  inches,  though,  when  the  coccyx  is  pushed  backward, 
the  distance  may  be  extended  to  four  and  a  half  inches. 

The  transverse  diameter,  betAveen  the  inner  borders  of  the  tuberos- 
ities, measures  four  and  a  quarter  inches. 


Fig.  94. — Section  showing  the  inclination  of  the  pelvis  according  to  Naegele.    (Tamier  et 

Chantreuil.) 


Owing  to  the  elasticity  of  the  sciatic  ligaments,  the  oblique  diam- 
eters are  not  regarded  as  of  obstetrical  importance. 

The  axis  of  the  inferior  strait,  when  the  coccyx  is  not  disturbed, 
strikes  the  promontory.  When  the  coccyx  is  pushed  backward,  a  per- 
pendicular line  drawn  from  the  center  impinges  upon  the  lower  bor- 
der of  the  first  sacral  vertebra. 

The  circumference  of  the  inferior  strait  measures  thirteen  and  a 
half  inches. 

The  pelvic  cavity  or  canal  possesses  an  irregular,  cylindrical  shape, 
constricted  somewhat  above  at  the  superior  strait,  and  narrowing  rap- 
idly at  the  pelvic  outlet.  Below  the  brim,  the  dimensions  are  in- 
creased considerably  by  the  concavity  of  the  sacrum.  Thus,  a  plane 
passing  through  the  lower  portion  of  the  symphysis  pubis,  and  across 


152 


LABOR. 


the  upper  margins  of  the  ace  tabula,  to  the  junction  of  the  second  and 
third  sacral  vertebrae,  gains  three  quarters  of  an  inch  in  th^  conjugate, 
while  the  transverse  diameter  is  barely  one  fourth  of  an  inch  less  than 
the  transverse  diameter  of  the  brim.  The  narrowing  at  the  outlet  is 
most  marked  in  a  plane  drawn  so  as  to  intersect  the  spines  of  the 
ischia  and  the  extremity  of  the  sacrum.  At  the  level  indicated,  the 
distance  between  the  spines  (transverse  diameter)  is  but  four  inches, 
and  the  antero-posterior  diameter  four  and  a  half  inches. 

The  sciatic  spines  divide  the  pelvic  cavity  into  two  unequal  sec- 
tions. In  the  larger,  anterior  section,  the  lateral  walls  slope  toward 
the  symphysis  and  arch  of  the  pubes,  while  posteriorly  the  walls  slope 
in  the  direction  of  the  sacrum  and  coccyx.  The  declivities  in  front 
of  the  spines  are  termed  the  anterior  inclined  planes  of  the  pelvis,  over 
which  rotation  of  the  occiput  takes  place  in  the  mechanism  of  normal 

labor.  Behind  the  spines  the  lateral 
slopes  are  known  as  the  posterior  inclined 
planes.  Meeting  together  in  the  median 
line  of  the  sacrum,  they  constitute  a  sort 
of  vault,  into  wliich  the  face  is  turned 
after  rotation  is  completed. 

The  general  direction  of  the  pelvic 
cavity  is  best  shown  by  a  line  represent- 
ing the  axis  of  the  bony  channel.  It 
should,  however,  be  stated  in  advance 
that  the  so-called  pelvic  axis  of  obstetri- 
cal writers  is  not  to  be  construed  as  the 
median  line  of  a  cylinder  in  a  strict 
mathematical  sense,  but  is  really  intended 
to  indicate  very  nearly  the  course  which 
a  round  body  like  the  fetal  head  would  naturally  pursue  in  its 
course  through  the  parturient  canal.  In  practice  it  is  convenient 
to  follow  the  suggestion  of  Hodge,  and  draw  a  plane  from  the  supra- 
pubic ligament  backward  to  the  sacrum,  and  parallel  to  the  plane  of 
the  superior  strait.  This  second  parallel  would  intersect  the  middle 
portion  of  the  second  sacral  vertebra.  Inasmuch  as  the  pubic  walls 
run  nearly  parallel  to  the  upper  portion  of  the  sacrum,  the  axis  of  the 
cavity  included  between  the  two  planes  may  be  regarded  as  continu- 
ous with  the  axis  of  the  brim.  Below  the  second  plane,  owing  to  the 
curvature  of  the  sacrum,  the  axis  describes  a  nearly  circular  course^ 
with  intersecting  planes  radiating  from  the  lower  border  of  the  sym- 
physis as  a  center.  Further  on  it  will  be  shown  that  the  axial  curve  is 
continued  beyond  the  bony  canal  by  the  distended  tissues  which  form 
the  floor  of  the  pelvic  basin. 

Differences  between  the  Male  and  Female  Pelvis. — In  the  male  the 
bones  of  the  pelvis  are  thick  and  solid  ;  the  brim  is  triangular  in 


MECHANISM  OF  LABOR. 


153 


shape  ;  the  promontory  projecting  ;  the  cavity  deep,  and  sloping  in- 
ward like  a  funnel ;  the  sacrum  long,  narrow,  and  moderately  curved  ; 
and  the  arch  of  the  pubes  is  formed  at  an  angle  of  from  75°  to  80°. 
In  the  female,  on  the  contrary,  the  bones  are  lighter  and  more  delicate 
in  contour,  therein  corresponding  to  the  inferior  muscular  develop- 
ment of  the  sex  ;  the  brim,  owing  to  the  less  marked  jutting  inward 
of  the  promontory,  has  an  elliptical  outline  ;  the  diameters,  both 
antero-posterior  and  transverse,  are  increased ;  the  pelvic  inclination 
is  more  pronounced ;  the  sacrum  is  wider  and  more  concave  ;  the 
tuberosities  of  the  ischia  are  wider  apart ;  the  angle  of  the  arch  of  the 
pubes  measures  from  90°  to  100°  ;  and  the  entire  depth  of  the  pelvis 
is  diminished.  As  a  result  of  the  increased  transverse  diameter  in  the 
female,  the  trochanters  are  at  a  greater  relative  distance  from  one 
another,  and  are  directed  somewhat  obliquely  to  the  front.  This 
peculiarity  brings  the  knees  in  close  proximity,  and  accounts  for  the 
characteristic  feminine  gait. 

The  configuration  of  the  female  pelvis,  though  unfavorable  to 
rapid  locomotion,  is,  in  a  special 
degree,  adapted  to  render  possible 
the  birth  of  the  child.  A  female 
pelvis  approximating  in  type  to 
that  of  the  male  gives  rise  to  a 
variety  of  dystocia  of  a  very  formi- 
dable character. 

Differences  between  the  Infan- 
tile and  Adult  Pelvis. — In  the  in- 
fantile pelvis  the  promontory  occu- 
pies a  relatively  higher  position 
above  the  upper  border  of  the  sym- 
physis ;  the  last  lumbar  and  two 
upper  sacral  vertebrae  possess  a 
moderate  convexity — i.  e.,  the 
promontory  does  not  project  for- 
ward, as  in  the  adult ;  the  sacrum, 
after  running  a  straight  course,  be- 
gins to  curve  forward  first  at  the 
fourth  vertebra  ;  the  alse  are  slight- 
ly developed ;  the  inclination  of 
the  ilia  more  nearly  approaches  the 
perpendicular  ;  the  S-shaped  curve 
of  the  crests  is  barely  indicated, 
there  being  but  slight  difference 
in  the  distances  between  the  crests 
and  anterior  superior  spines  ;  the  conjugate  diameter  in  proportion  to 
the  transverse  is  increased  ;  the  side-walls  converge  toward  the  outlet ; 


Fig.  9G. — Vertical  section  of  a  female  infan- 
tile pelvis.  (Feliling.) 


154 


LABOR. 


the  pubic  arch  is  formed  at  an  acute  angle  ;  and  the  distance  between 
the  spines  of  the  ischia  is  greater  than  the  transverse  diameter  of  the 
outlet. 

Distinctions  pertaining  to  sex  are  but  slightly  accentuated.  In 
the  female,  the  sacrum,  owing  to  the  smaller  size  of  the  yertebrse,  is 
narrower  than  in  the  male  ;  the  side- walls  are  higher ;  the  symphysis 
lower  ;  the  iliac  incline  approaches  more  nearly  a  vertical  line  ;  the 
pubic  arch  is  less  acute  ;  and  the  transverse  diameter  is  increased. 

The  most  important  agent  in  effecting  the  changes  which  char- 
acterize the  adult  pelvis  is  unquestionably  the  weight  of  the  trunk. 
Owing  to  the  wedge-shape  of  the  sacrum,  and  the  shelf -like  ledge 
which  projects  from  the  lower  surface  of  the  iliac  articulation,  no  dis- 
placement can  take  place  in  the  direction  of  the  long  axis  of  the  au- 


FiGs.  97,  98. — Diagrammatic  representations  of  sections  through  the  infantile  and  aduit 

pelves.  (Schroeder.) 


ricular  surfaces.  But,  when  we  bear  in  mind  the  inclination  of  the 
pelvis,  it  is  obvious  that  pressure  from  above  must  act  upon  the  sa- 
crum likewise  in  a  downward,  forward,  and  inward  direction.  Now,  if 
the  sacrum  were,  as  it  is  sometimes  represented,  the  key-stone  of  the 
pelvic  arch,  its  position  would  be  fixed  between  the  ilia.  We  owe  to 
Duncan,'*  however,  the  demonstration  that  this  view  is  incorrect,  and 
that  in  reality  the  sacral  articulation  slopes  backward  and  inward  in 
the  direction  of  the  median  line.  The  fact  that  the  sacrum  does  not 
under  pressure  drop  from  the  arch  is  due  to  the  strong  sacro-iliac 
ligaments,  which  hold  it  in  position  as  part  of  the  bony  ring.  The 
ligaments  do  not,  however,  prevent  the  sacrum  from  sinking  forward 
to  a  limited  extent  into  the  pelvic  cavity,  as  is  shown  in  the  projection 
backward  at  maturity  of  the  tuberosities  of  the  ilia,  whereas  in  the 
infantile  pelvis  the  dorsal  surface  of  the  sacrum  is  level  with  the  pos- 
terior superior  spinous  processes. 

*  Duncan,  "  Researches  in  Obstetrics." 


MECHANISM  OF  LABOR. 


155 


As  the  line  of  gravity  of  tlie  trunk  falls  in  front  of  the  sacrum, 
the  weight  from  above  presses  the  promontory  forward  and  inward 
toward  the  symphysis  pubis.  At  the  same  time  the  rotation  backward 
of  the  sacral  apex  is  restrained  by  the  sciatic  ligaments.  The  natural 
effect  of  these  two  simultaneously  operative  forces,  acting  at  a  period 
when  ossification  is  still  incomplete,  is  to  increase  the  sacral  curve, 
and  consequently  to  shorten  the  distance  between  the  upper  and  lower 
ends  of  the  base.  As  a  result,  the  height  of  the  promontory  is  dimin- 
ished, the  pelvic  brim  and  outlet  become  constricted,  and  the  dimen- 
sions of  the  pelvic  cavity  are  increased.  The  upper  portion  of  the 
sacrum,  in  rotating  forward,  drags  upon  the  posterior  ligamentous  at- 
tachments of  the  ilia.  This  traction  would,  were  it  not  for  their  union 
at  the  symphyses,  and  the  pressure  of  the  heads  of  the  thigh-bones, 
cause  the  ossa  innominata  to  revolve  around  the  sacral  articular  sur- 
faces, like  doors  upon  their  hinges.  As  a  result  of  the  antagonistic 
action  of  the  symphysis  and  the  sacro-iliac  ligaments,  however,  the 
ossa  innominata  bend  at  the  point  of  least  resistance  in  front  of  the 
sacrum,  and  in  this  way  an  increase  takes  place  in  the  transverse  at  the 
expense  of  the  antero-posterior  diameter. 

The  sexual  differences  are  attributable  to  differences  in  the  char- 
acter of  the  pelvic  contents  and  the  external  sexual  organs,  to  differ- 
ences in  muscular  development,  and  to  certain  distinctive  peculiarities 
of  growth.  Thus,  in  the  female  eunuchs  of  India,  described  by 
Roberts,*  there  were  absence  of  vagina  and  complete  atrophy  of  cellular 
tissue  in  the  genital  organs  ;  at  the  same  time  the  pelvis  approximated 
to  the  male  type,  and,  in  place  of  the  pubic  arch,  the  rami  of  the 
pubes  and  ischia  appeared  as  though  they  were  in  contact  at  the  site 
usually  occupied  by  the  vagina. 

In  fetal  life,  the  female  sacrum,  owing  to  the  smaller  size  of  the 
vertebrae,  is  narrower  than  in  the  male.  Subsequently  the  more  rapid 
growth  of  the  alae  becomes  the  cause  of  the  increased  width  which 
characterizes  the  sacrum  of  the  female  at  maturity.  The  larger  cir- 
cumference of  the  brim  in  the  female  is  due  partly  to  this  difference 
in  the  width  of  the  sacrum  and  partly  to  the  greater  length  of  the 
linea  innominata. 

The  Soft  Parts  of  the  Pelvis. — Prefatory  to  the  history  of  the  im- 
pregnated ovum,  we  have  already  considered  the  more  important  pel- 
vic viscera  concerned  in  generation  and  parturition.  In  studying  the 
mechanism  of  labor,  it  is,  however,  necessary  in  addition  to  recall — 
1.  The  soft  tissues  which  encroach  upon  the  pelvic  space  ;  2.  The 
structures  which  close  in  the  openings  of  the  pelvis,  and  convert  it 
into  a  basin-like  cavity. 

1.  The  diameters  of  the  brim  are  diminished  somewhat  by  the 
ilio-psoae  muscles.    The  iliac  muscles  proper  occupy  the  entire  surface 

*  Vide  Tilt,  "  Uterine  and  Ovarian  Inflammation,"  p.  63. 


156 


LABOR. 


of  the  internal  iliac  fossae.  The  fibers  converge  below,  and,  passing 
beneath  Poupart's  ligament,  become  united  to  the  borders  of  the  psoas 
muscle.    The  pelvic  portion  affords  a  soft  cushion  for  the  support  of 


Fig.  99. — Pelvis  covered  with  the  soft  parts,  with  removal  of  bladder,  uterus,  and  rectum. 


the  gravid  uterus.  The  great  psoas  muscles  fill  out  the  spaces  upon 
the  sides  of  the  promontory.  They  take  their  origin  from  the  lateral 
surfaces  of  the  bodies  and  transverse  processes  of  the  four  upper  lum- 
bar and  the  last  dorsal  vertebrae.  They  cross  the  pelvis  parallel  to  the 
linea  innominata,  which,  however,  they  slightly  overlap.  They  taper 
below,  and,  passing  beneath  the  femoral  arch,  terminate  in  a  tendon, 
which  is  inserted  into  the  small  trochanter.  These  two  muscles  flex 
the  thighs  upon  the  abdomen.  The  iliac  muscle  likewise  acts  as  an 
abductor,  and  the  psoas  serves  to  flex  the  pelvis  upon  the  spinal  col- 
umn. The  ilio-psoas  muscles  diminish  the  transverse  diameter  nearly 
a  half -inch,  so  that  the  latter  becomes  very  nearly  equal  in  length  to 
the  oblique  diameters.    When  the  limbs  are  extended  and  the  muscles 


MECHANISM  OF  LABOR. 


157 


are  rendered  tense,  the  influence  they  exert  in  lessening  the  pelvic 
space  is  somewhat  greater  than  when  they  are  relaxed  by  flexing  the 
legs  npon  the  thighs. 

The  large  arteries  and  veins  at  the  pelvic  brim  do  not  undergo  com- 
pression during  labor  under  normal  conditions.  When,  however,  con- 
siderable disproportion  exists  between  the  pelvis  and  the  child's  head, 
the  effects  of  pressure  are  sometimes  manifested  in  the  swelling  of  all 
the  soft  tissues  within  the  pelvic  cavity — a  swelling  which,  in  turn, 
enhances  the  difficulties  of  delivery. 

2.  The  open  spaces  of  the  pelvis,  which  are  closed  in  by  soft 
parts,  are  the  great  sciatic  notches,  the  obturator  foramina,  and  the 
pelvic  outlet. 


Fig.  100.— Section  of  pelvis,  showing  the  pyramidal  muscles.    (Tarnier  et  Cliantreuil.) 

The  closure  of  the  sacro-sciatic  notches  is  effected  by  the  pyramidal 
muscles.  The  pyramidal  muscle  has  a  triangular  shape.  Its  base 
presents  a  series  of  digitations  which  are  inserted  upon  the  lateral 
portions  of  the  anterior  surface  of  the  sacrum,  along  the  outer  borders 
of  the  four  lower  sacral  foramina  and  the  upper  portion  of  the  sacro- 
sciatic  ligament.  It  then  crosses  the  large  sciatic  foramen,  and, 
passing  outward,  terminates  in  a  tendon,  which  is  inserted  into  the 
large  trochanter. 

The  obturator  foramen  is  covered  by  the  internal  obturator  mus- 
cle. The  latter  is  attached  to  the  quadrilateral  surface  which  corre- 
sponds to  the  cotyloid  cavity,  to  the  circumference  of  the  foramen,  and 
to  the  inner  surface  of  the  obturator  membrane.  Its  fibers  converge 
to  form  a  tendon,  which  passes  through  the  lesser  sciatic  foramen,  and 
thence  is  directed  downward  and  backward  to  the  digital  cavity  of  the 
great  trochanter. 


158 


LABOR. 


Owing  to  their  tenuity,  neither  the  pyramidal  nor  the  obturator 
muscles  appreciably  affect  the  dimensions  of  the  pelvic  cavity. 


LARGE  SAC  RC -SCIATIC  LIG. 

Fig.  101. — Section  of  pelvis,  showing  the  internal  obturator  muscle.    (Tarnier  et  Chantreuil.) 

The  outlet  of  the  pelvis  is  closed  by  a  succession  of  layers,  which 
together  constitute  the  perineal  or  pelvic  floor.  These  layers,  passing 
from  without  inward,  consist  respectively  of  the  external  cutaneous 
tissue,  the  muscular  layers  with  their  associated  aponeuroses,  the  sub- 
peritoneal cellular  tissue,  and  the  peritonseum. 


■OBTURATOR 

INT. 


Fig.  102.— Muscles  of  the  perineal  floor,  as  seen  from  the  abdominal  cavity.    The  pyramidal 

muscle  has  been  removed. 

The  most  important  structure  which  enters  into  the  formation  of 
the  perineal  floor  is  the  Icvator-ani  muscle.    This  muscle  is  composed 


MECHANISM  OF  LABOR. 


159 


of  two  symmetrical  halves,  attached  in  front  to  the  inner  surface  of  the 
body  and  horizontal  rami  of  the  pubes,  and  laterally  to  the  tendinous 
arch  of  the  pelvic  fascia  which  stretches  from  the  inner  border  of  the 
pubes  to  the  spines  of  the  ischia.  Its  fibers  slope  anteriorly  down- 
ward and  inward  to  the  sides  of  the  bladder,  between  and  to  the  sides 
of  the  bladder  and  rectum,  and  posteriorly  are  inserted  into  a  tendinous 
raphe,  extending  from  the  extremity  of  the  coccyx  to  the  rectum. 
Its  rectal  insertions  become  confounded  with  the  upper  fibers  of  the 
external  sphincter  ;  those  of  the  vagina  are  situated  beneath  the  bulbs 
of  the  vestibule  and  the  constrictor  cunni.  The  ischio-coccygeus  is  a 
small  triangular  muscle,  by  many  included  in  the  description  of  the 
levator  ani.  It  is  situated  between  the  latter  and  the  pyramidal  mus- 
cle, and  in  front  of  the  small  sciatic  ligament.    Its  base  is  attached  to 


Fig.  103.— Antero-posterior  section  of  the  perineal  floor.    (Tarnier  et  Chantreuil.) 

the  sides  of  the  coccyx  and  lower  extremity  of  the  sacrum  ;  the  inser- 
tion of  the  apex  is  at  the  spine  of  the  ischium.* 

The  upper  surface  of  the  levator-ani  and  coccygeal  muscles  is  con- 
cave. The  muscles  themselves  are  flattened,  and  of  nearly  membra- 
nous thinness.  Alone  they  are  capable  of  affording  but  feeble  support 
to  the  superimposed  viscera.  They  are,  however,  above  closely  at- 
tached to  the  strong  tissues  of  the  internal  pelvic  fascia,  which  pos- 
sess the  qualities  of  elasticity  and  toughness. 

The  internal  pelvic  fascia  is  attached  to  the  upper  border  of  the 
superior  strait  where  it  meets  the  fascia  which  lines  the  iliac  fossae, 

*  The  coccygeus  muscle  is  strongly  developed  in  caudate  animals,  and  enables  them 
to  move  the  tail  laterally. 


^  ^THREE  LAYERS  Of 
THE  PERINEAL  FASCIA 


160 


LABOR. 


and  the  transverse  fascia  of  tlie  abdominal  walls.  It  covers  the  py- 
ramidal and  the  upper  half  of  the  obturator  muscles.  In  front  it  de- 
scends from  the  symphysis  to  the  neck  of  the  bladder,  and  forms  the 
pubo-vesical  ligament.  From  the  linea  terminalis  to  the  arcus  ten- 
dineus  the  fascia  upon  the  side-walls  is  firmly  attached  to  the  perios- 
teum. The  tendinous  arch  marks  the  line  at  which  the  fascia  leaves 
the  pelvic  walls  to  form  the  inner  lining  of  the  levator  and  coccygeal 
muscles. 

The  upper  surface  of  the  internal  pelvic  fascia  is  covered  by  the 
peritonaeum,  with  which  it  is  connected  by  loose  connective  tissue. 

The  fascial  coverings  beneath  the  levator-ani  muscle  are  divided 
into  a  posterior  and  anterior  portion  by  a  line  drawn  between  the  two 
ischia. 

The  posterior  portion  consists  of  a  single  layer.  It  starts  from  the 
sacro-sciatic  ligaments  and  the  tuberosities  of  the  ischia  ;  thence  it 
mounts  upward  over  the  inner  surfaces  of  the  ischia  and  the  obtura- 
tor internus  muscle  to  the  tendinous  arch,  which  it  contributes  to  form, 
and  from  the  tendinous  arch  is  reflected  at  an  acute  angle  over  the 
inferior  surface  of  the  levator-ani  muscle.  The  space  thus  limited 
between  the  side-walls  of  the  pelvis  and  the  levator  ani  is  termed  the 
ischio-rectal  excavation. 

The  anterior  portion,  or  perineal  fascia  proper,  fills  the  space  be- 
tween the  bis-ischiatic  line  and  the  arch  of  the  pubes.  It  is  composed  of 
three  layers,  as  follows  :  1.  The  deep  perineal  fascia,  which  covers  the 
lower  surface  of  the  levator  ani ;  2.  The  median  perineal  fascia,  sep- 
arated from  the  former  by  a  narrow  interval,  and  inclosing  the  pudic 
vessels  and  nerves ;  3.  The  superficial  perineal  fascia  which  forms, 
with  the  median  layer,  a  shallow  compartment  in  which  are  lodged 
the  superficial  muscles  of  the  perinaeum,  the  bulbs  of  the  vagina, 
the  vulvo-vaginal  glands,  and  the  rami  of  the  clitoris.  Each  one  of 
these  organs,  except  the  latter,  is,  moreover,  enveloped  in  a  special 
sheath,  derived  from  prolongations  of  the  upper  surface  of  the  apo- 
neurosis. 

The  superficial  perineal  muscles  are  of  slight  obstetrical  importance. 
They  are  the  constrictor  vagina,  the  ischio-cavernosi,  and  the  trans- 
versi  perinaei. 

The  constrictor  vaginae  consists  of  two  small  lateral  muscles,  situ- 
ated upon  the  outer  sides  of  the  vestibular  bulbs,  and  surrounding  the 
vulvar  orifice.  Posteriorly  the  extremities  of  the  main  muscle  start 
from  the  perineal  fascia  at  a  point  nearly  midway  between  the  sphinc- 
ter ani  and  the  ischia,  while  a  small  bundle  only  is  connected  with  the 
sphincter  ani  itself.*  Above,  the  convergent  ends  separate  into  a 
superficial  and  deep  portion.  The  superficial  portions  terminate  in  a 
tendon  which  unites  them  together  above  the  dorsal  vein  of  the  clito- 
*  LusciiKA,  "  Anatomic  des  menschlichcn  Beckcns,"  p.  399. 


MECHANISM  OF  LABOR.  161 

ris  ;  the  deep  portions  pass  between  the  upper  ends  of  the  bulbs  and 
the  clitoris,  and  are  likewise  united  by  an  aponeurosis. 

The  action  of  the  muscle  consists  chiefly  in  compressing  the  veins 


Fig.  104. — Muscles  of  the  perinseum.  (Henle.) 


crossed  by  its  tendon,  and  in  thus  enhancing  the  turgidity  of  the 
erectile  apparatus.  It  is  in  no  sense  a  sphincter  muscle,  though,  by 
pressing  the  turgid  bulbs  inward,  it  may  narrow  the  vestibule  of  the 
vagina. 

The  ischio-cavernosi  muscles  form  a  sort  of  fibro-muscular  sheath 
about  the  crura  of  the  clitoris.  They  are  united  together  above  by  an 
aponeurosis  which  crosses  the  posterior  extremity  of  the  body  of  the 
clitoris.  During  sexual  excitement  these  muscles  are  capable  not  only 
of  compressing  the  crura,  thereby  forcing  the  blood  toward  the  body 
of  the  clitoris,  but,  through  the  pressure  exerted  by  the  aponeurosis 
upon  the  dorsal  vein,  they  help  to  retard  the  return  of  the  blood  from 
the  turgescent  organ. 

The  transversi  perinaei  muscles  are  small,  triangular,  flattened 
muscles  which  pass  from  the  inner  sides  of  the  ischia,  underneath  the 
constrictor  muscle,  to  the  sides  of  the  vagina  and  rectum.  When  the 
11 


162 


LABOR. 


perinaenm  is  lacerated,  these  muscles  tend  to  produce  gaping  of  the 
wound,  and  to  interfere  with  union  by  first  intention. 

A  mere  enumeration,  such  as  has  been  given,  of  the  thin,  flat,  mus- 
cular and  aponeurotic  structures  of  the  pelvic  floor  affords,  however, 
a  very  incomplete  idea  of  the  true  anatomy  of  the  lower  portion  of  the 
parturient  canal.  Both  as  regards  form  and  function,  the  role  of  the 
connective  tissue  which  fills  out  all  the  available  interstices  between 
the  different  organs,  the  different  muscular  groups  and  the  bony  walls, 
is  of  the  highest  importance.  It  is  to  this  tissue  that  the  perineal 
body  occupying  the  space  between  the  vagina  and  rectum  owes  its  ex- 
traordinary distensibility.  In  a  sagittal  section,  the  perineal  body 
presents  a  triangular  shape,  with  a  convex  vaginal  and  concave  rectal 
surface.*  Laterally  it  spreads  out  to  the  rami  and  the  tuberosities  of 
the  ischia.  In  height  it  extends  upward  nearly  one  half  the  length  of 
the  vagina.  Between  the  border  of  the  anus  and  the  inner  commissure 
of  the  vulva,  the  external  portion,  which  forms  the  base  of  the  tri- 
angle, measures  on  the  average  an  inch  in  length. f    When  the  head  of 


Fig.  105. — The  parturient  canal.  (Hodge.) 


the  child,  during  labor,  descends  below  the  level  of  the  bony  walls, 
it  bulges  the  peringeum  and  stretches  it  from  four  to  five  inches  in  the 
antero-posterior  direction.  Both  the  length  and  degree  of  curvature 
of  the  pelvic  canal  are  thereby  increased,  the  soft  parts  posterior  to 

*  Thomas,  "The  Female  Perinaenm,"  etc.,  "Am.  Jour,  of  Obstet.,"  April,  1880. 
f  Foster,  F.  P.,  "  Anatomy  of  the  Uterus  and  its  Surroundings,"  "  Am.  Jour,  of 
Obstet.,"  January,  1880. 


MECHANISM  OF  LABOR. 


163 


the  Yulva  forming  a  gutter-like  extension,  the  axis  of  which  is  con- 
tinuous with  that  of  the  pelvis. 

The  Head  of  the  Fcetus  at  Term. 

The  head  is  the  part  which  presents  the  greatest  mechanical  diffi- 
culties in  the  passage  of  the  foetus  through  the  parturient  canal.  It 
is,  therefore,  important  to  become  familiar  with  its  shape,  its  diameters, 
and  the  modification  it  undergoes  during  labor. 

In  studying  the  fetal  head  we  distinguish  the  face  and  the  cranium. 

The  face  is  of  little  importance  in  normal  labors.  It  may,  how- 
eyer,  be  here  incidentally  noted,  what  is  sometimes  of  consequence  in 
extreme  degrees  of  pelvic  contraction,  that  the  distance  (two  and  a 
half  inches)  between  the  malar  bones  possesses  but  a  slight  degree  of 
reductibility. 

In  the  cranium  we  distinguish  again  between  the  upper  compressi- 
ble portion  or  vault  and  the  lower  incompressible  portion  or  base  of 
the  skull.  The  vault  is  composed  of  the  frontal  and  parietal  bones 
and  the  squamous  portions  of  the  temporal  and  occipital  bones.  The 
base  is  formed  by  the  union  of  the  ethmoid,  the  sphenoid,  the  petrous 
portion  of  the  temporal  bones,  and  the  basilar  portion  of  the  occipital 
bone. 


Fig.  100. — Lateral  view  of  fetal  Fig.  107. — Fetal  head,  as  seen  from 

skull.    (Hodge.)  above.  (Hodge.) 

The  Sutures  and  Fontanelles. — The  flat  bones  which  form  the  vault 
are  thin  and  imperfectly  ossified,  consisting,  indeed,  of  little  more  than 
the  diploe.  Instead  of  union  by  serrated  osseous  borders,  they  are 
held  in  their  relative  positions  by  the  periosteum  and  dura  mater, 
which  come  into  contact  with  one  another  and  form  membranous  com- 
missures between  the  bones.  Where  more  than  two  bones  meet  at  a 
given  point,  the  ossification  is  apt  to  be  incomplete,  and  spaces  are  left, 
covered  only  by  membranes,  termed  fontanelles. 

The  sutures  to  which  it  will  be  found  necessary  to  make  constant 
reference  are  the  following  :  the  frontal  suture,  situated  between  the 
ununited  halves  of  the  frontal  bone  ;  the  coronal  suture,  between  the 
frontal  and  parietal  bones ;  the  sagittal  suture,  where  the  parietal  bones 
meet  at  the  top  of  the  cranium  ;  the  lambda  suture,  so  called  from  its 
resemblance  to  the  Greek  letter  of  that  name,  between  the  triangular 


164 


LABOR. 


portion  of  the  occipital  and  the  posterior  borders  of  the  parietal 
bones. 

At  the  point  of  intersection  of  the  frontal,  the  sagittal,  and  the 
coronal  sutures  the  incomplete  ossification  of  the  frontal  and  parietal 
bones  leaves  a  large  open  space  of  a  rhomboidal  shape,  termed  the  an- 
terior or  large  fontanelle,  or  sometimes  simply  the  bregma.  Of  the 
four  sides,  the  anterior  are  longer,  often  extending  for  some  distance 
between  the  bones  of  the  os  frontis. 

The  posterior  or  small  fontanelle  is  situated  at  the  junction  of 
the  sagittal  and  lambda  sutures.  It  is  formed  at  the  meeting  of  three 
bones,  viz.,  the  two  parietal  and  the  occipital,  and  possesses  a  triangu- 
lar shape.  In  very  many  cases  the  ossification  of  the  bones  is  complete 
at  the  time  of  delivery.  Its  site  then  is  indicated  by  the  angle  formed 
by  the  posterior  borders  of  the  parietal  bones,  beneath  which,  as  a 
consequence  of  labor,  the  occipital  bone  is  usually  found  depressed. 

Budin  has  recently  demonstrated  that  the  squamous  or  triangular 
portion  is  attached  to  the  basilar  portion  of  the  occipital  bone  by  means 
of  a  band  of  cartilaginous  and  fibrous  tissue.  A  sort  of  hinge-joint  is 
thus  formed,  which  permits  veritable  movements  of  flexion  and  exten- 
sion to  take  place.* 

The  flexibility  of  the  cranial  bones,  the  sutures,  the  fontanelles, 
and  the  fibro-cartilaginous  bands  of  union,  together  enable  very  con- 
siderable changes  to  take  place  in  the  diameters  of  the  fetal  head 
during  the  progress  of  labor. 

The  Diameters  of  the  Fetal  Head. — The  diameters  of  the  child's 
head  are  a  series  of  imaginary  lines  extending  between  fixed  points, 
selected  so  as  to  indicate  the  dimensions  of  the  largest  segments  which, 
in  the  different  positions  and  presentations,  engage  in  the  pelvic  canal. 
We  distinguish  diameters  running  in  the  antero-posterior,  the  trans- 
verse, and  the  vertical  directions,  f 

The  antero-posterior  diameters  are  :  1.  The  occipito-mental ;  2.  The 
occipito-frontal ;  3.  The  sub-occipito-bregmatic. 

The  occipito-mental  diameter  extends  from  the  highest  point  of 
the  occiput  to  the  chin  ;  I  the  occipito-frontal,  from  the  occiput  to 
the  root  of  the  nose  ;  the  sub-occipito-bregmatic,  from  the  junction 
of  the  occiput  with  the  neck  to  the  point  of  intersection  in  the  large 
fontanelle  of  the  coronal  and  sagittal  sutures. 

The  transverse  diameters  are  :  1.  The  bi-parietal ;  2.  The  bi-tem- 
poral ;  3.  The  bi-mastoid. 

*  Budin,  "  Dc  la  Tete  du  Foetus,''  p.  12. 

f  The  points  of  departure  of  the  following  diameters  have  been  adopted  from  Budin's 
excellent  monograph,  already  quoted. 

The  occipito-mental  diameter  is  usually  referred  to  as  the  longest  one  of  the  head. 
According  to  Budin,  the  true  maximum  diameter  is  situated  between  the  chin  and  a  vari- 
able point  in  the  line  of  the  sagittal  suture  above  the  occiput. 


MECHANISM  OF  LABOR. 


165 


The  bi-parietal  diameter  stretches  between  the  two  bosses  or  pro- 
tuberances of  the  parietal  bones  ;  the  bi-temporal,  between  the  extremi- 


FiG.  108. — Antero-posterior  and  vertical  diameters  of  the  fetal  head.    (Tarnier  et  Chantreuil. ) 

ties  of  the  coronal  sutures ;  the  bi-mastoid,  between  the  mastoid  pro- 
cesses at  the  base  of  the  skull. 

The  vertical  diameters  are  :  1.  The  fronto-mental ;  2.  The  cervico- 
bregmatic. 

The  fronto-mental  diameter  extends  from  the  top  of  the  forehead 
to  the  point  of  the  chin  ;  the  cervico-bregmatic,  from  the  middle  of 
the  large  fontanelle  to  the  upper  portion  of  the  neck  near  the  larynx. 

In  furnishing  standard  measurements  of  the  foregoing  diameters 
it  is  of  course  understood  that  no  two  heads  present  precisely  the  same 
dimensions.  As  a  rule,  as  shown  by  Sir  J.  Y.  Simpson,  the  heads  of 
boys  are  larger  than  those  of  girls.  In  selecting  type-cases  it  will  be  re- 
membered too,  that,  owing  to  the  plasticity  of  the  head,  in  none  are  the 


BI-PARIETAL. 


BI-TEMPORAL- 


Fio.  109.— Diagram  showing  transverse  diameters  of  fetal  head.    (Tarnier  et  Chantreuil.) 

diameters  completely  normal  immediately  after  the  transit  through 
the  generative  passages.    Unless,  therefore,  the  child  is  delivered  by 


166 


LABOR. 


Caesarean  section,  sufficient  time  should  be  allowed  to  elapse  after  de- 
livery before  the  measurements  are  made,  to  permit  the  head  to  return 
to  its  natural  shape.  Again,  as  in  the  measurements  of  the  pelvis, 
the  figures  selected  to  represent  the  normal  average  should  be  such  as 
admit  of  convenient  recollection. 

DIAMETERS  OF  FETAL  HEAD.* 


Occipito-mental  diameter   5 J  inches. 

Occipito-frontal      "    4^  " 

Sub-occipito-bregmatic  diameter   3|  " 

Bi- parietal  "     3|  " 

Bi-temporal  "    3^  " 

Bi-mastoid  "    3  " 

rronto-mental  "    3|-  " 

Cervico-bregmatic  "    3|  " 


The  circumference  of  the  head,  from  the  chin  to  the  vertex,  using 
the  latter  term  to  express  the  highest  part  of  the  skull,  without  refer- 
ence to  any  fixed  anatomical  point,  is  about  fourteen  and  three  quar- 
ters inches.  The  circumference  at  the  sub-occipito-bregmatic  diameter 
is  but  thirteen  inches. 

The  Articulation  of  the  Head  with  the  Spinal  Column. — The  move- 
ments of  the  occiput  upon  the  atlas  are  extremely  limited,  those  of 
extension  and  flexion,  which  the  head  executes  so  readily,  taking  place 
for  the  most  part  in  the  articulations  of  the  cervical  vertebrae.  Move- 
ments of  rotation  are  performed  at  the  articulation  between  the  axis 
and  the  atlas.  In  practice,  the  head  can  not  be  turned  with  safety  to 
either  side  beyond  a  quarter  of  a  circle,  though,  when  rotation  is  per- 
formed slowly  after  delivery,  it  may  sometimes  be  carried  to  such  an 
extent  as  to  enable  the  face  to  look  directly  backward.  The  insertion 
of  the  spinal  column  at  a  point  nearer  to  the  occipital  than  the  frontal 
extremity  of  the  child's  head  is  of  supreme  importance  in  the  further- 
ance of  the  mechanical  processes  of  labor.  It  converts  the  head  into 
a  lever,  consisting  of  two  unequal  portions.  When  the  head,  there- 
fore, encounters  circular  resistance  in  passing  through  the  obstetric 
canal,  pressure  transmitted  through  the  spinal  column  causes  the  de- 
scent of  the  occipital  short  end  of  the  lever,  while  the  pressure  upon 
the  forehead  from  the  side-walls  flexes  the  chin  upon  the  thorax,  the 
degree  of  flexion  depending  upon  the  size  of  the  canal  through  which 
the  transit  is  made. 

*  The  diameters  given  are  based  upon  the  table  in  Tarnier  and  Chantreuil,  which 
were  averaged  from  measurements  taken  with  great  precision  in  forty-four  cases. 


MECHANISM  OF  LABOR. 


167 


CHAPTER  IX. 

MECHANISM  OF  LA  BOB.  — ( Con  tinued. ) 

Presentations :  natural,  unnatural,  normal. — Vertex  presentations  :  frequency,  positions. 
— Manner  in  which  head  enters  pelvis. — Positions,  normal  mechanism  of  labor. — 
Descent  and  flexion. — Rotation. — Extension. — External  rotation. — Expulsion  of  the 
trunk. — Abnormal  mechanism  (vertex  presentations). — Mechanism  of  occipito-poster- 
ior  positions. — Configuration  of  the  head  in  vertex  presentations. — Molding. — Scalp- 
tumor. — Diagnosis  of  vertex  presentations. 

The  meclianism  of  labor — i.  e.,  the  manner  in  which  the  foetus 
passes  through  the  parturient  canal  —  varies  with  the  presenta- 
tion. 

The  presentations  are  classified,  in  the  first  place,  with  reference 
to  the  position  of  the  foetus  in  relation  to  the  axis  of  the  uterus.  In 
cases  where  the  long  diameter  of  the  foetus  coincides  with  that  of  the 
uterus,  we  have  further  to  distinguish  presentations  of  the  head  and 
presentations  of  the  pelvic  extremity. 

Head  presentations  comprise  those  of  the  vertex,  brow,  and 
face. 

Pelvic  presentations  offer  two  varieties,  viz.,  breech  presentations, 
and  foot  presentations. 

When  the  long  diameter  of  the  foetus  crosses  the  axis  of  the  uterus, 
there  is  produced  a  transverse,  or,  after  the  operation  of  uterine  con- 
tractions, a  shoulder  presentation. 

Vertex,  face,  and  pelvic  presentations  are  included  in  the  category 
of  natural  labors.  Brow  and  shoulder  presentations  are  termed  unnat- 
ural, as,  with  few  exceptions,  they  are  not  terminable  except  by  the 
resources  of  the  obstetric  art. 

Vertex  presentations  alone  are  to  be  regarded  as  normal,  as  they 
only  realize  the  mechanical  conditions  compatible  with  the  highest 
degree  of  safety  to  both  mother  and  child. 

In  the  following  pages  it  is  purposed  to  associate  with  the  descrip- 
tions of  the  mechanism  of  labor,  in  the  various  presentations  and  posi- 
tions, an  account  of  the  means  of  diagnosis,  and  the  treatment  suited 
to  the  special  cases  under  consideration,  instead  of  placing  diagnosis, 
mechanism,  and  treatment  in  chapters  distinct  from  one  another. 
The  writer  believes,  from  long  experience  in  teaching,  that  what  is  thus 
sacrificed  in  the  way  of  systematic  completeness  is  more  than  compen- 
sated by  the  clinical  advantage  of  keeping  in  close  proximity  the  prin- 
ciples of  obstetric  art  and  the  rules  of  practice  directly  deducible  from 
them. 

Precedence  of  description  is  given  to  the  vertex  presentation  as 
representing  the  normal  type  of  labor. 


168 


LABOR. 


Vertex  Presentatioks. 

In  93,871  births,  collected  from  private  practice,  Spiegelberg  found 
that  m  over  ninety-seven  per  cent,  the  cranial  vault  presented.*  The 
back  of  the  child  in  utero  is  directed  in  about  seventy  per  cent,  of 
cases  to  the  left,  and  in  thirty  per  cent,  to  the  right,  side  of  the  mother. 
The  fronto-occipital  diameter  of  the  head  measures  four  and  a  half 
inches.  The  diameters  of  the  pelvic  brim,  after  deducting  the  soft 
parts,  are  nearly  as  follows  : 

Transverse  diameter  of  brim  4|  to  5  inches. 

Oblique  "  "   4|  to  5  inches. 

Antero-posterior  diameter  of  brim  (minimum  diameter 

about  one  third  inch  below  the  crista  pubis)  4  inches. 

Thus  it  will  be  seen  that  the  fronto-occiptal  diameter  of  the  head 
may,  at  the  brim,  enter  the  pelvis  without  meeting  with  any  special 
resistance  in  either  the  transverse  or  oblique  diameters.  In  the  conju- 
gate diameter,  on  the  contrary,  this  is  not  possible.  Transverse  posi- 
tions, where  the  conditions  are  normal,  are  of  very  exceptional  occur- 
rence, though  they  form  the  rule  in  flattened  pelves.  TarnierJ 
suggests  that  this  infrequency  is  partially  explicable  on  mechanical 
grounds.  The  long  transverse  diameter  of  the  pelvis,  he  says,  is, 
owing  to  the  projection  of  the  promontory,  situated  in  a  line  consid- 
erably posterior  to  the  point  at  which  the  sagittal  suture  normally 
meets  the  conjugate.  When  the  head,  therefore,  enters  the  pelvis  in  a 
transverse  direction  with  both  parietal  bones  upon  the  same  plane,  the 
fronto-occipital  diameter  corresponds  to  a  shortened  chord  subtending 
two  points  of  the  pelvic  ring  in  front  of  the  anatomical  transverse 
diameter  ;  in  point  of  fact,  therefore,  the  latter,  at  the  site  of  engage- 
ment, is  less  than  either  of  the  oblique  diameters.  In  flattened  pelves 
this  difficulty  does  not  exist,  as,  in  place  of  both  parietal  bones  entering 
upon  the  same  level,  the  posterior  is  turned  toward  the  corresponding 
shoulder,  the  anterior  dipping  obliquely  into  the  brim  (lateral  obliquity 
of  Naegele),  an  arrangement  by  which  the  long  diameter  of  the  head 
is  brought  into  correspondence  with  the  long  diameter  of  the  pelvis. 

At  the  time  when  the  sagittal  suture  is  accessible,  and  it  is  possible 
to  observe  with  correctness,  the  antero-posterior  diameter  of  the  head 
is  found  to  approximate  to  one  or  the  other  of  the  pelvic  oblique  diam- 
eters. 

It  is  customary  to  classify  the  positions  of  the  head  with  reference 
to  the  direction  of  the  occiput.  Most  English  authorities  admit  four 
varieties,  viz. : 

The  right  occipi to-anterior  (R.  0.  A.),  the  right  occipi to-posterior 

*  Spiegelberg,  "Lehrbuch  dcr  Geburtshiilfc,"  p.  148. 

X  Tarnier  et  Chantreuil,  "  Trait6  de  I'Art  des  Accouchements,"  p.  465. 


MECHANISM  OF  LABOR. 


169 


(R.  0.  P.),  the  left  occipito-anterior  (L.  0.  A.),  the  left  occipito-pos- 
terior  (L.  0.  P.). 

Naegele  first  called  attention  to  the  fact  that  the  head  occupies,  in 
an  overwhelming  proportion  of  cases,  the  left  oblique  diameter ;  that, 
therefore,  when  directed  to  the  left,  the  occiput  is  turned  to  the 
cotyloid  cavity,  and,  when  directed  to  the  right,  it  looks  toward  the 
sacro-iliac  synchondrosis.*  This  peculiarity  probably  results  from  the 
fact  that  the  uterus  is  usually  rotated  in  such  a  way  upon  the  spine 
that  the  right  side  inclines  obliquely  backward,  while  the  left  side  is 
turned  somewhat  to  the  front. 

In  practice  it  is  convenient  to  take  simply  into  account,  in  the  first 
place,  the  question  whether  the  occiput  is  turned  to  the  right  or  to  the 
left,  and  then  to  observe  specifically  whether  it  occupies  a  position  in 
front  or  to  the  rear  of  the  transverse  diameter. 

At  the  beginning  of  labor  the  head,  surrounded  by  the  lower  seg- 
ment of  the  uterus,  is  commonly  found  at  the  brim  or  resting  upon 
an  iliac  fossa  in  multiparae,  and  below  the  brim,  within  the  pelvic 
cavity,  in  primiparse.  The  direction  of  the  head,  as  regards  its  vertical 
axis,  depends  upon  the  degree  of  resistance  afforded  by  the  contigu- 
ous uterine  tissues.  In  the  softened,  relaxed  condition  often  ob- 
servable in  multiparae  toward  the  close  of  pregnancy,  the  two  fonta- 
nelles  are  not  infrequently  situated  upon  the  same  level.  Where  the 
lower  uterine  walls  are  firm  and  slope  toward  the  os  internum,  the 
weight  of  the  child's  body,  transmitted  through  the  vertebral  column, 
depresses  the  occiput.  At  the  same  time  the  sloping  uterine  walls, 
acting  upon  the  frontal  extremity  of  the  child's  head,  direct  the  chin 
toward  the  thorax,  thus  producing  a  state  of  semi-flexion. 

The  Normal  Mechanism  of  Labor. 

The  mechanism  of  labor  in  head  presentations  is  usually  described 
as  consisting  of  a  series  of  acts,  termed  respectively  descent,  flexion, 
rotation,  external  restitution,  expulsion  of  the  trunk. 

A  familiarity,  not  with  the  names  of  the  various  acts,  but  the  things 
the  names  represent,  is  essential  to  the  judicious  prosecution  of  the 
obstetric  art. 

Descent  and  Flexion. — Descent  and  flexion  go  hand  in  hand,  and 
should  be  associated  in  thought  as  they  are  in  reality.  It  is  evident, 
whenever  the  head  encounters  the  resistance  of  the  obstetric  canal, 
the  force  transmitted  through  the  spine  to  the  foramen  magnum  will 
cause  the  descent  of  the  occiput,  and  thus  flexion  will  result.  The 
degree  of  flexion,  however,  is  proportioned  to  the  extent  of  the  action 
of  the  walls  upon  the  frontal  extremity  of  the  head,  and  therefore  is 

*  When  the  head  is  said  to  occupy  an  oblique  diameter,  this  is  not  intended  to  be 
understood  in  a  mathematical  sense.  The  expression  implies  simply  that  the  head  is 
deflected  from  the  transverse  diameter. 


170 


LABOR. 


variaWe  in  different  subjects  and  in  different  portions  of  the  canal. 
This  will  best  be  shown  by  considering  the  two  acts  in  conjunction. 
The  descent  of  the  child's  head  through  the  cervix  is  effected  by 


Fig.  110. — Figure  illustrating  the  mechanism  of  labor  in  occipito-anterior  deliveries  (after 

Schultze). 


the  pressure  of  the  uterus  during  contraction  upon  its  entire  contents. 
While  not  denying  the  possibility  of  the  transmission  of  a  certain 
amount  of  propulsive  energy  from  the  uterine  walls  through  the  trunk 
of  the  child  to  the  head,  it  is  necessarily  of  feeble  force,  as  the  flexi- 
bility of  the  spine  and  the  smoothness  of  the  breech  prevent  the  latter 
from  finding  a  suitable  point  d^appui  against  the  vaulted  fundus.  The 
head  is,  however,  subjected  to  the  driving  force  of  the  fluid  medium 
with  which  the  fcetus  is  surrounded.  As  the  pressure  is  proportioned 
to  the  height  of  the  fluid,  in  the  case  of  partial  flexion,  the  force 
directed  against  the  depressed  occiput  is  greater  than  that  expended 
upon  the  frontal  extremity.  This  condition  not  only  promotes  the 
continuance  of  head-flexion,  but  contributes  to  its  increase  as  the 
head  in  its  descent  meets  with  the  resistance  of  the  cervical  canal.* 

The  head  enters  the  pelvis  in  the  axis  of  the  brim,  with  the  bi- 
parietal  diameter  parallel  with  the  planes  of  the  superior  strait.  This 
direction  it  maintains  until  arrested  by  the  curvature  of  the  sacrum 
and  by  the  floor  of  the  pelvis. 

In  its  transit  through  the  cervix,  it  is  usual  for  the  head-flexion  to 

*  Laiis,  "  Die  Theorie  der  Geburt,"  p.  199. 


MECnANISM  OF  LABOR. 


171 


become  complete — i.  e.,  for  the  chin  to  sink  until  arrested  by  contact 
with  the  chest.  Exceptions  to  this  rule  are  found  in  cases  where  the 
head  is  unusually  small,  or  where,  as  is  sometimes  the  case  in  multi- 
parae,  the  cervix,  after  rupture  of  the  membranes,  is  so  softened  and 
dilatable  as  to  offer  slight  hindrance  to  the  advancement  of  the  head. 
It  is  well  for  the  beginner  to  keep  constantly  in  mind  that  flexion  is 
not  in  any  sense  an  active  movement.  It  is  always  a  movement  of 
accommodation,  the  end  of  which  is  the  successive  substitution  of  a 
shorter  diameter  for  a  previous  longer  one,  so  soon  as  the  latter  has 
encountered  sufficient  resistance  to  arrest  its  further  progress.  The 
mechanical  advantages  of  flexion  are  obvious  when  we  recall  that  the 
average  length  of  the  sub-occipito-bregmatic  or  maximum  diameter  of 
the  flexed  head  (four  inches)  is  a  half-inch  less  than  the  occipito- 
frontal or  maximum  diameter  of  the  head  when  midway  between  ex- 
tension and  flexion.  Again,  the  maximum  circumference  of  the  flexed 
head  (thirteen  inches)  is  one  and  three  fourths  inches  less  than  one 
measured  about  the  extremities  of  the  occipito-frontal  diameter. 
These  measurements,  which  are  representative  of  the  natural  state, 
are,  however,  far  from  expressing  the  full  extent  of  the  differences 
which  exist  after  the  plastic  head  has  undergone  the  molding  processes 
incident  to  labor  {vide  p.  178). 


Fig.  111. — Vertex  presentation  ;  child  surrounded  by  amniotic  fluid.   (Tarnicr  et  Chantreuil.) 

A  further  advantage  of  flexion  is  thus  described  by  Professor  Pajot : 
The  foetus,  in  its  entirety,  is  to  be  regarded  as  a  broken,  vacillating 
rod,  possessed  of  mobility  at  the  articulation  of  the  head  and  trunk  ; 


172 


LABOR. 


but  a  solid  thus  disposed  presents  conditions  unfavorable  to  the  trans- 
mission of  a  force  acting  principally  upon  one  of  its  extremities ;  it 
follows,  therefore,  that  previous  to  flexion  the  uterine  action,  pressing 
upon  the  pelvic  extremity  to  promote  the  advance  of  the  foetus,  is  lost 
in  great  measure  in  its  passage  from  the  trunk  to  the  head,  by  reason 
of  the  mobility  of  the  latter ;  but  the  cephalic  extremity,  once  fixed 
upon  the  thorax,  is  most  advantageously  disposed  to  participate  in  the 
impulse  communicated  to  the  general  mass  of  the  foetus."  *  Now,  al- 
though we  have  seen  that,  in  its  descent  through  the  cervix,  the  head 
is  for  the  most  part  propelled  by  the  direct  action  of  the  fluid  pressure  ; 
just  in  proportion  to  its  advance  into  the  pelvis,  the  propulsive  force 
exerted  during  a  contraction  operates  more  and  more  exclusively  upon 
the  trunk,  until  the  conditions  mentioned  by  Professor  Pajot  are  com- 
pletely realized. 

After  the  head  is  once  released  from  the  environment  of  the  cer- 
vical canal,  a  slight  movement  of  extension  may  follow,  provided  the 
resistance  offered  by  the  vagina  is  less  than  that  of  the  cervix.  In 
many  cases,  on  the  contrary,  where  dilatation  is  complete  at  the  time 
of  rupture  of  the  membranes,  the  head  may  pass  through  the  cervix 
with  scarcely  any  change  in  its  direction,  flexion  taking  place  first 
when  the  head  encounters  the  resistance  of  the  sloping  pelvic  walls  and 
the  perineal  floor. 

Rotation. — The  head,  as  we  have  seen,  follows  the  axis  of  the  su- 
perior strait  until  arrested  by  the  extremity  of  the  sacrum  and  the 
perineal  floor.  As  it  nears  the  latter,  the  curvature  of  the  sacrum  ap- 
proximates the  posterior  wall  to  the  sagittal  suture.  Upon  vaginal 
examination,  the  finger  comes  in  contact  with  the  anterior  half  of  the 
head  as  the  presenting  part.  It  is  not,  however,  on  that  account  to 
be  assumed  that  the  head  is  inclined  laterally  toward  the  posterior 
shoulder,  though  the  sensation  produced  deceptively  favors  such  a 
theory,  f 

When  the  head  has  once  reached  the  perineal  floor,  its  further 
progress  is  associated  with  the  most  interesting  of  the  mechanical  acts 
of  labor.  The  occiput,  whether  previously  directed  to  the  anterior  or 
posterior  extremity  of  an  oblique  diameter,  turns  forward  under  the 
arch  of  the  pubes,  until  the  sagittal  suture  occupies  very  nearly  the 
antero-posterior  diameter  of  the  outlet.  The  utility  of  this  movement 
is  obvious.    Owing  to  the  inward  slope  of  the  side-walls  of  the  pelvis, 

*  Pajot,  "  Dictionnaire  encyclopedique  des  sciences  medicales,"  t.  i,  p.  382,  quoted 
by  Tarnier  et  Chantrcuil,  p.  639. 

f  With  the  apparent  obliquity  it  is  probable  that  a  certain  amount  of  real  obliquity 
coexists.  As,  even  in  extreme  flexion,  the  lateral  movements  of  the  head  are  not  inter- 
fered with,  it  is  hardly  to  be  expected  that  the  head,  when  arrested  at  the  perineal  floor, 
would  continue  to  maintain  a  right  line  with  the  spine.  The  movement  possesses,  how- 
ever, no  special  significance  as  a  factor  in  the  mechanism  of  labor,  and  its  mention  is 
simply  the  addition  of  a  needless  detail  to  an  already  sufficiently  complex  process. 


MECHANISM  OF  LABOR. 


173 


the  distance  between  the  ischia  is  but  four  and  a  quarter  inches,  and 
between  the  spines  four  inches.  If,  in  unskillful  forceps  operations, 
the  head,  previous  to  rotation,  is  dragged  through  the  transverse  diam- 
eter of  the  pelvis  by  main  force,  it  becomes  enormously  flattened  and 
lengthened  in  the  direction  of  the  trachelo-bregmatic  diameter,  the 
child's  life  is  endangered,  and  the  soft  parts  of  the  mother  are  jeop- 
ardized. AYhen,  however,  rotation  is  completed,  the  bi-parietal  diam- 
eter (four  inches),  which  is  capable  of  sustaining  a  considerable  degree 
of  lateral  compression,  engages  in  the  transverse  diameter  of  the  pel- 
vis ;  at  the  same  time  the  sub-occipito-bregmatic  engages  in  the  con- 
jugate diameter.  The  latter,  though  measuring  but  three  and  three 
fourths  inches,  may  be  extended  to  four  and  a  half  inches  by  the 
pressing  backward  of  the  tip  of  the  coccyx. 

The  conditions  for  the  forward  rotation  of  the  occiput  are — 1. 
Flexion  ;  2.  Good  labor-pains  ;  3.  A  firm  perinaeum. 

In  either  of  the  occipito-anterior  positions  rotation  is  not  diffi- 
cult to  understand.  The  convergent  anterior  inclined  planes  furnish 
smooth  surfaces  upon  which  the  occiput  glides  downward  and  forward 
to  the  front.  *  The  rigid  ischial  spines  direct  the  forehead  to  the  sacro- 
sciatic  ligaments,  which  determine  the  backward  movement  corre- 
sponding to  that  of  the  occiput  in  the  front  part  of  the  pelvis.* 

M.  Pajot  expresses  the  law  which  governs  the  rotation  movements 
in  the  following  terms  :  '^When  a  solid  body  is  contained  within  an- 
other, if  the  receptacle  (contenant)  is  the  seat  of  alternations  of  move- 
ment and  repose,  and  its  surfaces  are  slippery  and  but  slightly  angular, 
the  contained  body  will  tend  increasingly  to  accommodate  its  form 
and  dimensions  to  the  form  and  capacity  of  the  receptacle."  f 

In  occipi to-posterior  positions,  the  rotation  of  the  occiput  forward 
is,  at  the  first  glance,  a  puzzling  phenomenon,  as  the  inclined  planes 
of  the  pelvis,  the  ischial  sjiines,  and  the  law  of  accommodation,  pre- 
viously invoked  by  way  of  explanation,  should  determine  the  rotation 
of  the  occiput,  not  to  the  front,  but  to  the  sacral  cavity.  The  follow- 
ing experiment  of  Dubois,  however,  throws  considerable  light  upon 
the  principal  conditions  of  success:  **In  a  woman  who  had  died  a 
short  time  previous  in  child-bed,  the  uterus,  which  had  remained 
flaccid  and  of  large  size,  was  opened  to  the  cervical  orifice,  and  held 
by  aids  in  a  suitable  position  above  the  superior  strait ;  the  foetus  of 
the  woman  was  then  placed  in  the  soft  and  dilated  uterine  orifice  in 
the  right  occipito-posterior  position.  Several  pupil-midwives,  pushing 
the  foetus  from  above,  readily  caused  it  to  enter  the  cavity  of  the  pelvis  ; 
much  greater  effort  was  needed  to  make  the  head  travel  over  the  peri- 
naeum  and  clear  the  vulva  ;  but  it  was  not  without  astonishment  that 
we  saw,  in  tliree  successive  attempts,  that  when  the  head  had  traversed 

*  Leishman,  "  The  Mechanism  of  Parturition,"  p.  76. 

f  Martel,  "  L'accommodation  en  obstetriquc,"  vide  introduction. 


174 


LABOR. 


the  external  genital  organs,  the  occiput  had  turned  to  the  right  ante- 
rior position,  while  the  face  had  turned  to  the  left  and  to  the  rear ;  in 
a  word,  rotation  had  taken  place  as  in  natural  labor.  We  repeated  the 
experiment  a  fourth  time,  but  as  the  head  cleared  the  vulva  the  occi- 
put remained  posterior.  Then  we  took  a  dead-born  foetus  of  the  pre- 
vious night,  but  of  much  larger  size  than  the  preceding  ;  we  placed  it 
in  the  same  conditions  as  the  first,  and  twice  in  succession  witnessed 
the  head  clear  the  vulva  after  having  executed  the  movement  of  rota- 
tion. Upon  the  third  and  following  essays,  delivery  was  accomplished 
without  the  occurrence  of  rotation  ;  thus  the  movement  only  ceased 
after  the  perinaeum  and  vulva  had  lost  the  resistance  which  had  made 
it  necessary,  or,  at  least,  had  been  the  provoking  cause  of  its  accom- 
plishment." * 

This  interesting  experiment  shows  that  it  is  unnecessary  to  assume 
a  vis  vert  ens,  or  rotation  force,  in  the  uterus  itself.  A  certain  amount 
of  light  is  i-hrown  upon  the  action  of  the  perineal  floor  by  the  clinical 
fact  that  it  is  always  the  most  dependent  portion  of  the  presenting 
part  which  rotates  to  the  front.  A  moment's  reflection  will  show  that 
rotation,  therefore,  takes  place  in  such  a  direction  that  the  sloping  sur- 
face of  the  child's  head  is  brought  into  correspondence  with  the  down- 
ward slope  of  the  perinseum.  Thus  it  sometimes  happens,  in  occipi to- 
posterior  positions,  that  moderate  extension  occurs,  so  that  the  large 
fontanelle  is  felt  below  the  plane  of  the  small  one.  In  this  case,  the 
head  rests  with  its  entire  length  upon  the  perineal  floor ;  its  move- 
ments are  of  necessity  restrained  within  narrow  limits  ;  and,  if  exten- 
sion persists,  the  pressure  of  the  opposing  ischio-pubic  ramus  directs 
the  forehead  under  the  arch  of  the  pubes.  When,  however,  the  head 
is  well  flexed  it  no  longer  corresponds  to  the  perineal  plane.  The  occi- 
put then  glides  downward,  and  is  projected  forward  by  the  elastic 
pelvic  floor  until  the  anterior  parietal  boss  is  forced  between  the  ischio- 
pubic  rami.  As  the  occipital  end  of  the  flexed  head  descends  down- 
ward and  forward  toward  the  pubic  arch,  the  frontal  extremity  en- 
counters the  resistance  of  the  pelvic  wall  near  the  ileo-pectineal  emi- 
nence. If  the  pressure  upon  the  head  were  in  all  parts  equal,  no  fur- 
ther progress  would  no  w  be  possible.  But  it  is  not  equal.  The  back- 
ward pressure  applied  to  the  frontal  portion  of  the  head  is  exerted 
upon  the  long  end  of  a  lever,  and  works,  therefore,  at  a  greater  mechan- 
ical advantage  than  that  directed  against  the  occiput,  f  At  the  same 
time,,  if  the  anterior  wall  be  divided  by  a  line  drawn  on  a  level  with 
the  lower  margin  of  the  symphysis,  we  find  that  in  the  superior  divis- 
ion the  general  pelvic  pressure  diminishes  from  before  backward,  while, 
below  the  line  indicated,  pressure  diminishes  from  behind  forward. 
Now,  in  accordance  with  the  mechanical  principle  that,  when  a  body  is 

*  Martel,  "  De  I'accommodation  en  obstctrique,"  quotation,  p.  93. 
f  Tarnier  et  Chantreuil,  "  Trait6  de  I'art  des  accouchements,"  p.  644. 


MECHANISM  OF  LABOR. 


175 


subjected  to  various  pressures,  tlie  movement  will  take  place  in  the 
direction  of  the  least  pressure,*  we  find  that  the  frontal  portion,  which 
lies  above  the  sub-pubic  plane,  turns  backward,  while  the  occiput,  which 
lies  below,  turns  under  the  arch  of  the  pubis. 

It  must  not  be  supposed,  in  imagining  the  results  of  rotation,  that 
the  movement  continues  until  exact  coincidence  of  the  sagittal  suture 
and  the  conjugate  is  reached.  Leishman  endeavored  to  measure  tlie 
divergence  between  the  two  after  the  head  had  escaped  from  under 
the  pelvic  arch,  by  stretching  a  cord  over  the  surface  of  the  head  from 
the  lower  border  of  the  symphysis  to  the  coccyx.  He  found  that  in 
left  occipital  positions  the  cord  crossed  the  lambdoidal  suture  about  an 
inch  to  the  right  of  the  small  fonta- 
nelle,  and  thence  extended  forAvard  to 
the  middle  of  the  opposite  orbit,  in- 
tersecting the  median  line  at  or  near 
the  anterior  fontanelle.  f 

In  emerging  from  the  pelvis,  the 
two  tubera  parietalia  do  not  pass  out 
at  the  same  time.  In  place  of  this, 
the  head  rolls  upon  its  side,  so  that 
in  left  occipital  positions  the  presen- 
tation is  formed  by  the  upper  and  pos- 
terior part  of  the  right  parietal  bone, 
and  in  right  occipital  positions  by  the 
corresponding  territory  upon  the  left 
parietal  bone. 

Extension. — As  the  head  clears  the 
inferior  strait  it  distends  the  perinae- 
um,  and  converts  it  into  a  groove, 
which  directs  the  occiput  toward  the 
vaginal  orifice.  With  the  descent  of 
the  head  the  perinaeum  lengthens  ;  be- 
tween the  pains  the  perinaeum  retracts, 
and  the  head  recedes.  A  gradual  soft- 
ening results  from  the  continuance  of  yig.  112. 
this  play,  and,  with  diminished  resist- 
ance from  the  i3erinaeum,  the  occiput 
descends  along  the  anterior  pelvic  wall,  the  trunk  enters  the  canity,  and 
the  neck  finds  support  against  the  os  pubis.  Flexion  continues  until 
the  occiput  engages  between  the  pubic  rami.    When  the  resistance  of 


0  B,  slioi-t  end  of  the  head 
lever  ;  B  F,  long  end  of  head  lever. 
(Tarnier  et  Chantrcuil.) 


*  Stephen-son,  "  On  the  Mechanism  of  Labor,"  "  Obstct.  Jour,  of  Gr.  Brit,  and  Ire.," 
October,  1878,  p.  405. 

f  Leishman,  "The  Mechanism  of  Parturition,"  p.  84,  It  will  be  readily  understood 
that,  in  right  occipital  positions,  the  cord  should  pass  from  the  left  of  the  small  fonta- 
nelle forward  to  the  right  orbit. 


176 


LABOR. 


the  anterior  bony  wall  is  no  longer  encountered,  the  surface  of  the 
child's  head  glides  forward  u]3on  the  perinseam,  as  upon  an  inclined 
plane,  and  describes  a  circle  beneath  the  pelvic  arch,  of  which  the  sub- 
occipito-bregmatic  diameter  forms  the  radius. 

The  extension  of  the  head,  which  is  an  essential  feature  of  the  fore- 
going movement,  is  the  resultant  of  two  forces — derived,  first,  from  the 
uterus  ;  second,  from  the  pelvic  floor. 

The  uterine  action  is  transmitted  in  the  axis  of  the  superior  strait. 
With  the  occiput  fixed  beneath  the  pubic  arch,  and  the  neck  resting 
against  the  inner  surface  of  the  pubes,  the  propulsive  force  is  expended 
upon  the  frontal  extremity  of  the  head,  and  this  causes  the  sejoaration 
of  the  chin  from  the  thorax.  So  soon  as  the  forehead  passes  the  apex 
of  the  sacrum,  the  recoil  of  the  coccyx  and  the  elastic  perinaeum  drives 
the  fronto-occipital  diameter  forward  to  the  vulva,  which  now  looks  in 
a  nearly  vertical  direction.  When  the  bi-parietal  diameter  has  once 
passed  the  vaginal  orifice,  the  perinaeum  rapidly  retracts,  and,  as  it 
glides  over  the  face,  the  occiput  is  thrown  sharply  and  rapidly  upward 
against  the  pubes. 

External  Rotation. — After  the  birth  of  the  head,  the  face,  no 
longer  supported  by  the  perinaeum,  sinks  toward  the  anal  region.  At 
the  same  time,  or  with  the  recurrence  of  a  pain,  the  head  makes  a 
quarter-rotation,  the  occiput  turning  toward  the  thigh  corresponding 
to  the  side  to  which  it  was  originally  directed  (right  occipital  posi- 
tion, right  thigh  ;  left  occipital  position,  left  thigh),  and  the  face 
to  the  internal  surface  of  the  opposite  thigh.  This  movement  is 
partly  a  restitution  of  the  head  to  its  normal  direction,  and  partly  is 
due  to  a  corresponding  rotation  of  the  shoulders  in  the  pelvic  cavity. 
To  understand  the  mechanism  of  external  rotation  it  must  be  borne 
in  mind  that,  in  the  movement  of  rotation  performed  by  the  head  in 
its  transit  through  the  pelvic  canal,  the  trunk  participates  to  a  dimin- 
ished extent  only.  Thus,  Schatz  *  found,  in  the  frozen  section  made  by 
Braune  through  the  cadaver  of  a  woman  who  died  in  the  second  stage 
of  labor,  where  the  head  had  originally  occupied  the  right  occipito- 
posterior  position,  that  the  deviation  between  the  pelvic  extremity  and 
the  head  was  measured  by  an  angle  of  thirty  degrees,  and  between  the 
head  and  trunk,  on  a  line  with  the  shoulders,  by  an  angle  of  thirteen, 
degrees.  After  the  release  of  the  head  from  the  vulva,  the  torsion 
ceases,  and  the  fetal  parts  resume  their  natural  relations  to  one  an- 
other. The  head,  therefore,  turns  slightly  to  the  side,  as  it  accommo- 
dates itself  to  the  direction  of  the  shoulders.  This  first  movement  is 
termed  "  restitution,"  and  is  much  less  marked  in  occipito-anterior  than 
in  occipito-posterior  positions.  The  shoulders  assume  an  oblique  posi- 
tion, until,  encountering  the  sloping  pelvic  planes,  the  anterior  shoul- 
der rotates  forward,  and  the  bis-acromial  diameter  approximates  to 

*  Schatz,  "Arch.  f.  Gynaek,,"  Bd.  vi,  p.  413. 


MECHANISM  OF  LABOR. 


177 


the  antero-posterior  diameter  of  the  outlet.  The  internal  rotation  of 
the  shoulders  usually  takes  place  suddenly,  and  is  accompanied  by  the 
corresponding  movement  of  the  child's  head. 

Excessive  rotation  is  sometimes  observed.  Thus,  the  shoulders,  in 
place  of  turning  to  the  antero-posterior  diameter,  may  continue  in 
movement  until  they  occupy  the  oblique  diameter  of  the  opposing 
side,  the  posterior  shoulder  coming  to  the  front.  This  necessarily 
causes  faulty  external  rotation  of  the  head.  It  occurs  most  frequently 
in  occipito-posterior  positions.* 

Expulsion  of  the  Trunk. — After  rotation,  the  anterior  shoulder 
passes  under  the  arch  of  the  pubes  ;  the  trunk,  as  it  is  driven  down 
from  above,  becomes  bent  laterally,  and  the  posterior  shoulder  glides 
forward  upon  the  perinseum  to  the  commissure  of  the  vulva ;  both 
shoulders  then  make  the  exit  from  the  vaginal  canal  simultaneously. 
In  the  delivery  of  the  shoulders,  the  bis-acromial  diameter  is  usually 
somewhat  oblique.  The  expulsion  of  the  trunk,  owing  to  the  previous 
dilatation  of  the  passage,  follows  with  rapidity ;  the  body  executes  a 
spiral  movement  until  the  hips  engage  at  the  outlet ;  during  the 
birth  of  the  pelvis,  however,  the  bis-iliac  diameter  rotates  so  as  to 
approximate  to  the  line  extending  from  the  coccyx  to  the  pubes. 

Ab2^okmal  Mechanism  of  Labor.    (Vertex  Presentation.) 

In  the  proper  performance  of  the  various  mechanical  acts  of  labor, 
it  is  necessary  that  the  diameters  of  the  fetal  head  approximate  to 
those  of  the  canal  through  which  it  has  to  pass.  A  very  large  pelvis, 
or  a  very  small  head,  may  become  disturbing  factors  by  leading  to 
imperfect  flexion  and  rotation.  In  either  case,  with  a  lax  perinaeum 
and  gaping  vulva,  the  head  may  be  born  in  any  of  the  diameters 
of  the  pelvis.  Head-births  in  either  an  oblique  or  transverse  diam- 
eter are,  however,  extremely  rare.  They  are  attended  with  unusual 
difficulty,  as  the  occiput  has  to  traverse  a  longer  course  than  when 
directed  forward  under  the  pubic  arch. 

The  most  important  of  the  irregular  forms  results  from  the  rota- 
tion of  the  occiput,  in  occipito-posterior  positions,  backward  into  the 
hollow  of  the  sacrum,  f  The  chief  condition  of  its  production  is  a 
partial  extension  of  the  head,  the  forehead  then  turning  anteriorly,  in 
accordance  with  the  law  that  the  most  dependent  portion  of  the  pre- 
senting part  is  moved  to  the  front. 

The  Mechanism  of  Occipito-posterior  Positions. — When  the  occiput 
turns  backward,  it  rests  upon  the  anterior  surface  of  the  sacrum  and 
upon  the  perinaeum  ;  the  forehead  and  the  anterior  fontanelle  distend 

*  DouRN,  "  Ueber  die  Ursachcn  fehlerhaftcs  Drehung  der  Schultern,"  etc.,  "  Arch.  f. 
Gynaek.,"  Bd.  iv,  p.  363. 

t  Playfair  states  that  Dr.  Uvcdale  West  found  the  frequency  of  this  backward  rotation 
was  four  times  to  the  hundred  in  occipito-posterior  positions.    American  edition,  p.  265. 
12 


178 


LABOR. 


the  vulva.  If  the  rotation  is  incomplete,  the  anterior  parietal,  or  adja- 
cent frontal  bones,  are  seen  at  the  rima  pudendi ;  and,  as  the  frontal 
portion  is  born,  the  occiput  sweeps  forward  to  the  perineal  commissure. 


Fig.  113. — Figure  illustrating  the  mechanism  of  labor  in  occipito-posterior  positions  (after 

Schultze). 


After  the  occiput  makes  its  exit,  the  neck  rests  upon  the  perinaeum, 
while  the  head  swings  backward,  describing  a  circle,  of  which  the  sub- 
oecipito-bregmatic  diameter  forms  the  radius. 

Delivery  in  these  cases  is  apt  to  be  tedious,  and  often  demands  the 
aid  of  forceps. 

COKFIGUKATION-  OF  THE  HeAD  II^  VeKTEX  PkESENTATIOKS. 

During  labor  the  various  head  diameters  of  the  foetus  undergo  ex- 
tensive modification  as  they  are  subjected  to  the  resistance  of  the  par- 
turient canal.  Of  these  the  most  important  is  the  diminution  of  the 
sub-occipito-bregmatic,  the  occipito-frontal,  and  the  bi-temporal  diam- 
eters, with  compensatory  elongation  taking  place  in  a  line  running 
from  the  chin  to  a  point  in  the  sagittal  suture  situated  between  the 
apex  of  the  occipital  bone  and  the  large  fontanolle  (maximum  diame- 
ter of  Budin).  The  plastic  changes  mentioned  are  rendered  possible 
by  the  presence  of  the  fontanelles,  the  width  of  the  sutures,  the  plia- 
bility of  the  sagittal  borders  of  the  parietal  bones,  the  depressibility  of 
the  OS  frontis,  and  the  joint-like  movement  between  the  squamous  and 
basilar  portions  of  the  occipital  bone.    As  a  consequence  of  these  ana- 


MECHANISM  OF  LABOR. 


179 


tomical  dispositions,  pressure  from  above  inclines  the  frontal  bones  back- 
ward, while  the  resistance  encountered  below  shoves  the  occipital  bone 
in  a  forward  direction.    These  movements  are  rendered  possible  by 


1.  2. 


Fig.  114. — Outlines  sliowing  difference  between  head  of  child  at  birth  (1)  and  four  days  sub- 
"  sequent  to  delivery  (2).  (Budin.) 


the  depression  of  both  frontal  and  occipital  bones  beneath  the  adjacent 
borders  of  the  parietal  bones ;  at  the  same  time  the  dragging  thus  ex- 
erted upon  the  latter,  front  and  rear,  increases  the  curve  of  the  cranial 
vault  along  the  line  of  the  sagittal  suture.  The  sharpness  of  the  bend 
at  the  summit  of  the  curve  is  more  or  less  pronounced,  according  to 
the  rigidity  of  the  channel  through  which  the  head  passes.  In  cases 
of  birth  with  the  occiput  to  the  rear,  the  head  is  often  drawn  out  to  a 
great  length,  the  occiput  forming  an  almost  vertical  line  with  the 
neck  and  shoulders,  while  in  front  the  forehead  and  parietal  bones 
slope  upward  to  the  vertex  in  nearly  the  same  plane.    (Fig.  115.) 

The  contour  of  the  head  is  still  further  modified  by  the  formation 
of  the  caput  succedaneum,  or  scalp-tumor,  a  swelling  developing  upon 
the  portion  of  the  presenting  part  which  is  subjected  to  diminished 
pressure  from  the  obstetric  canal,  and  which  in  consequence  becomes 
the  seat  of  venous  hyperaemia,  oedema,  and  extravasation.  The  forma- 
tion of  the  tumor  is  usually  preceded  by  a  wrinkling  of  the  scalp  indic- 
ative of  the  stronger  compression  above.  It  may  be  produced  within 
the  cervical  canal,  but  is  then  usually  of  insignificant  size,  and  of 
small  practical  importance.  Indeed,  it  may  even  form  previous  to 
rupture  of  the  membranes  in  cases  where  the  separation  of  the  bag  of 
waters  from  the  contents  of  the  uterine  cavity  is  complete,  and  where, 
we  have  seen,  the  water-pressure  below  the  line  of  cervical  contact 
with  the  head  is  less  than  the  intra-uterine  pressure  above.  IJsually, 
however,  it  is  developed  after  the  head  reaches  the  pelvic  floor,  at  the 


180 


LABOR. 


outlet  of  the  vagina,  the  situation  upon  the  scalp  often  enabling  one 
subsequent  to  delivery  to  diagnose  the  position  the  head  had  occupied 
within  the  pelvic  canal.* 

A  voluminous  scalp-tumor  is,  as  a  rule,  the  result  of  compression 
from  the  bony  canal,  and  forms,  therefore,  in  normal  pelves,  below 
the  narrowing  of  the  inferior  strait.  In  generally  contracted  pelves, 
however,  where  the  resistance  of  the  bony  canal  is  encountered  at  the 
brim,  the  formation  of  an  enormous  scalp-tumor  may  precede  the  en- 
trance of  the  head  into  the  pelvis. 

According  to  Dessau t,f  the  scalp-tumor  is  usually  of  larger  size 
when  situated  upon  the  anterior  surface  of 
the  head,  partly  because  of  the  greater  laxity 
of  the  tissues,  and  partly  because  of  the  longer 
duration  of  labor  when  the  forehead  is  di- 
rected to  the  front.  Its  length  may  vary 
from  a  half -inch  to  two  inches  or  more.  In 
extreme  cases,  where  the  labor  has  been  pro- 
longed, there  is  sometimes  found,  associated 
with  the  scalp-tumor,  a  separation  of  both  the 
periosteum  and  the  dura  mater  from  the  un- 
derlying segment  of  the  cranium. 

Diagnosis. — The  diagnosis  of  cranial  pres- 
entations by  external  palpation  is  usually  not 
difficult.  The  head  is  recognized  by  its  hard- 
FiG.  115.— Figure  showing  uess,  its  rounded  form,  its  separation  from 
the  trunk  by  the  neck,  and  the  ease  with 
which  ballottement  is  produced.  Sometimes, 
by  pressure  upon  the  cranial  bones,  a  pecul- 
iar parchment-like  crackle  is  elicited,  which  is  perceptible  even  through 
the  abdominal  parietes.J  The  breech,  on  the  contrary,  is  of  uneven 
shape,  of  smaller  size,  and  of  softer  consistence  ;  the  feet  are  found  in 
close  proximity  ;  ballottement  is  obscure  on  account  of  the  broad  con- 
nection between  the  breech  and  the  trunk.  Under  favorable  condi- 
tions the  back  presents  upon  one  side  of  the  uterus  a  broad,  palpable 


shape  of  head  in  occipito- 
posterior  deliveries.  (Tar- 
nier  et  Chantreuil.) 


*  The  tumor  forms  in  left  occipito-anterior  positions  upon  the  superior  posterior  angle 
of  the  right  parietal  bone,  encroaching  somewhat  upon  the  small  fontanelle  and  the  occi- 
put ;  in  right  occipito-anterior  positions,  upon  the  corresponding  point  upon  the  left  side 
of  the  cranium.  In  occipito-posterior  deliveries  the  tumor  develops  upon  the  anterior 
superior  angle  of  the  parietal  bone  turned  to  the  pubic  arch,  and  encroaching  upon  the 
large  fontanelle,  and  even  upon  the  frontal  suture.  If  the  head-rotation  is  complete,  and 
the  head  is  detained  for  a  long  period  at  the  vulva,  the  tumor  may  occupy  the  median 
line,  and  thus  obscure  the  diagnosis. 

f  Tarnier  et  Chantreuil,  p.  686. 

X  Fasbender,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxxiii,  p.  435.  Dr.  P.  F.  Munde  has  re- 
cently furnished  an  excellent  resume  of  the  subject  of  diagnosis  by  external  examination, 
in  an  essay  termed  "  Obstetric  Palpation." 


MECHANISM  OF  LABOR. 


181 


surface  without  distinctive  bony  projections.  The  position  of  the 
child  is  determined — 1.  By  the  fetal  heart,  which,  except  in  face-pres- 
entations, is  heard  most  distinctly  over  the  dorsal  surface  ;  2.  By  the 


Fig.  116. — Method  of  performing  external  palpation. 


direction  of  the  feet,  which  are  situated  upon  the  abdominal  side  of 
the  child. 

Upon  examination  made  per  vaginam  the  head  is  felt  as  a  hard, 
round,  smooth  body,  characterized  by  the  sutures  and  fontanelles,  and 
sufficiently  large  to  fill  the  space  of  the  pelvis.  Before  the  rupture  of 
the  membranes,  investigations  should  be  conducted  in  the  intervals  be- 
tween the  pains,  i.  e.,  while  the  membranes  are  lax  and  depressible.  If 
the  head  is  high,  and  retreats  before  the  examining  finger,  it  should  be 
steadied  by  counter-pressure  applied  to  the  fundus  uteri  through  the 
abdominal  walls. 

The  sutures  and  fontanelles  are  best  made  out  after  rupture  of  the 
membranes.  In  passing  the  extremity  of  the  index-finger  backward 
over  the  cranium  toward  the  sacrum,  the  sagittal  suture  is  usually  en- 
countered. At  the  extremities  of  the  sagittal  suture,  the  two  fontanelles 
are  perceived,  distinguishable  from  one  another  by  the  differences  in 
size  and  shape.  In  exceptional  cases,  the  extreme  compression  of  the 
bones  of  the  skull  may  render  the  large  fontanelle  scarcely  recognizable  ; 


182 


LABOR. 


in  others,  again,  the  presence  of  membranous  spaces  in  the  line  of  the 
sagittal  suture,  fissures  at  the  apex  of  the  occipital  bone,  or  the  exist- 
ence of  ossa  triquetra  near  the  site  of  the  small  fontanelle  may  cause 
perplexity,  and  lead  to  errors  in  the  diagnosis  of  head  positions.  It  is, 
therefore,  well  to  bear  in  mind,  as  special  marks  of  distinction,  that  the 
small  fontanelle  furnishes  the  meeting-point  of  three  sutures,  while 
four  sutures  meet  at  the  large  fontanelle. 

The  sagittal  suture  pursues  a  straight  course,  forming  a  right  angle 
with  the  coronal  and  an  obtuse  angle  with  the  lambda  suture.  An- 
teriorly it  is  continuous  with  the  frontal  suture  ;  posteriorly  it  ends 
abruptly  at  the  occipital  bone.  The  lambda  suture,  which  is  the  only 
one  liable  to  be  mistaken  for  the  preceding,  is  distinguished  by  its  cur- 
vilinear direction,  by  the  greater  thickness  of  the  parietal  borders,  and 
by  the  depression  of  the  occipital  beneath  the  parietal  bones. 

When  the  sutures  are  masked  by  the  presence  of  a  large  scalp-tumor, 
it  is  still  possible  in  most  cases  to  diagnose  the  position,  by  pushing  the 
finger  up  behind  the  symphysis  pubis  and  feeling  for  the  ear. 


CHAPTER  X. 

MECHANISM  OF  LABOR— {Continued). 

Face  presentations. — Frequency. — Causes. — Mechanism. — Descent  and  extension. — Rota- 
tion. —  Flexion.  —  External  Rotation.  —  Abnormal  mechanism.  —  Configuration  of 
head. — Diagnosis. — Prognosis. — Treatment. — Brow  presentations. — Breech  presenta- 
tions.— Causes. — Diagnosis. — Mechanism. — Irregular  mechanism. — Configuration. — 
Prognosis. — Treatment. 

Face  Peesentatioks. 

Ii^  facial  presentations,  in  place  of  the  normal  attitude  of  the  foetus, 
the  chin  is  extended,  the  occiput  is  reflected  against  the  neck,  and  the 
face  with  the  frontal  portion  of  the  skull  occupies  the  entrance  to  the 
pelvis.  It  is  not  a  very  common  anomaly,  having  occurred,  according 
to  Pinard,  320  times  in  81,711  confinements  at  i^he  Maternite  in  Paris, 
or,  in  round  numbers,  once  in  250  cases.* 

Causes. — The  causes  of  face  presentations  are  imperfectly  known. 
Clinical  observation  has,  however,  succeeded  in  connecting  the  exten- 
sion of  the  head  in  the  pelvic  canal  with  a  variety  of  predisposing  con- 
ditions. To  Ahlfeld  \  we  are  indebted  for  a  collection  of  associated 
events  derived  from  a  careful  analysis  of  well-observed  cases.  From 
these,  the  following  are  selected  because  of  their  more  palpable  con- 
nection with  the  phenomenon  in  question  : 

*  Charpentier,  "  Contributions  k  Tctudc  des  pr6sentation  dc  la  face,"  p.  15. 
\  Ahlfeld,  "  Die  Entstehung  der  Stirn-  und  Gesichtslagen." 


MECHANISM  OF  LABOR. 


183 


Separation  of  the  chin  from  the  chest,  resulting  from  congenital  en- 
largement of  the  thyroid  gland ;  from  increased  size  of  the  chest  in- 
terfering with  flexion  ;  from  stricture  of  the  cervix  about  the  neck  of 
the  child,  the  uterine  walls  adding  to  the  circumference  of  the  thorax; 
from  the  mobility  of  the  foetus,  either  because  of  its  small  size  or  from 
excess  of  amniotic  fluid  ;  from  oblique  positions  of  the  child  and  of  the 
uterus,  especially  in  cases  of  rapid  escape  of  the  amniotic  fluid ;  and 
from  coiling  of  the  cord  around  the  head  of  the  foetus.  Hecker* 
lays  great  stress  upon  the  shape  of  the  child's  head,  and  has  endeavored 
to  establish  a  connection  between  face  presentations  and  unusual 
length  of  the  occiput.  To  be  sure,  after  birth  in  face  presentations 
the  hind-head  is  often  found  to  nearly  equal  in  length  the  anterior 
portion,  and  it  is  easy  to  see  that,  were  such  the  case  at  the  beginning 
of  labor,  the  question  of  extension  or  flexion  would  always  be  in  sus- 
pense ;  but,  in  most  cases,  the  shape  is  the  effect  rather  than  the  cause 
of  the  presentation.  Still,  Hecker  and  others  have  reported  instances 
where  the  elongation,  instead  of  proving  temporary,  persisted  after  de- 
livery, and  therefore  it  was  fair  to  assume  had  existed  as  a  pre-natal 
condition. 

The  resistance  encountered  by  the  occiput,  which  converts  partial 
into  complete  extension  of  the  head,  may  be  furnished  by  either  the 
uterine  or  the  pelvic  walls. 

Most  writers  ascribe  great  importance  to  oblique  positions  of  the 
foetus  and  of  the  uterus  in  the  etiology  of  face  presentations.  In  mul- 
tiparas, the  former  are  not  uncommon  during  pregnancy,  the  head 
then  resting  upon  an  iliac  fossa.  As  a  rule,  however,  the  first  pains 
straighten  the  foetus,  the  narrowing  of  the  uterus  in  its  transverse 
diameter  serving  to  press  the  breech  toward  the  fundus  and  the  head 
into  the  pelvis.  So  long  as  the  back  of  the  child  is  directed  down- 
ward, the  rectification  would  inevitably  be  followed  by  head-flexion. 
When,  however,  the  back  is  turned  toward  the  fundus,  and  the  change 
to  the  vertical  attitude  is  not  readily  effected,  the  pressure  of  the  ad- 
jacent uterine  wall  may,  during  contraction,  act  in  a  special  degree  upon 
the  occiput,  and  direct  it  backward  toward  the  neck,  while  the  fore- 
head sinks  forward  into  the  brim  of  the  pelvis.  This  movement  is 
often  temporary,  and,  with  the  descent  of  the  child,  the  resistance  en- 
countered by  the  forehead  may  exceed  that  met  with  from  the  occiput, 
and  thus  in  the  end  flexion  may  follow  in  the  ordinary  manner.  If, 
however,  the  extension  continues,  a  point  is  finally  reached  at  which 
the  propelling  force  is  exerted  specially  in  the  direction  of  the  chin, 
now  converted  into  the  short  end  of  the  lever,  and  the  face  presenta- 
tion becomes  complete.  In  the  same  way,  extension  may  be  produced 
when  the  occiput  is  arrested  at  the  linea  innominata,  an  accident  most 
likely  to  occur  in  transverse  narrowing  of  the  pelvis,  and,  again,  in 

*  Hecker,  "  Ueber  die  Schadelform  bei  Grcsichtslagcn." 


184 


LABOR. 


flattened  pelves  when  the  bi-parietal  diameter  is  arrested  by  the  con- 
tracted conjugate.  The  mechanism  of  head-flexion  may  likewise  be 
interfered  with  by  a  prolapsed  extremity  encroaching  upon  the  pelvic 
space. 

In  lateral  obliquity  of  the  uterus,  the  curvature  of  the  uterine 
canal  favors  the  production  of  face  presentations  when  the  back  of 
tlie  child  conforms  to  the  convexity  of  the  lower  surface,  as  the  pro- 
pelling force,  which  is  transmitted  in  the  axis  of  the  uterus,  then 
passes  along  the  anterior  aspect  of  the  foetus,  and  increases  the  ten- 
dency of  the  forehead  to  descend. 

While  in  vertex  presentations  the  left  dorsal  positions  are  nearly 
three  times  as  frequent  as  the  right,  in  face  presentations  the  difference 
is  very  small.*  Both  Duncanf  and  Schroeder  ;|;  ascribe  this  relative 
preponderance  of  face  presentations  with  the  chin  directed  to  the  left 
to  the  constancy  of  right  lateral  obliquity  of  the  uterus. 

Ahlfeld  *  mentions  further  that  it  is  not  infrequent  for  extension 
to  take  place  within  the  pelvic  cavity,  the  arrest  of  the  occiput  result- 
ing from  an  unusual  projection  of  the  spines  of  the  ischia. 

The  Mechai^ism  of  Face  Peesen^tatioxs. 

As  in  vertex  presentations,  the  dorsum  of  the  child  may  be  turned 
to  the  right  or  the  left  side.  The  position  of  the  face  is  usually  des- 
ignated by  the  direction  of  the  chin.    We  distinguish,  therefore  : 

Eight  mento-iliac  positions  (chin  to  right  ilium)  ; 

Left  mento-iliac  positions  (chin  to  left  ilium) . 

Most  frequently  the  face  occupies  the  left  oblique  diameter  of  the 
pelvis.  The  common  positions  are,  therefore,  the  right  mento-iliac 
posterior,  and  the  left  mento-iliac  anterior  ;  still,  it  is  by  no  means 
rare  for  the  face  to  enter  the  pelvis  transversely,  probably  because  of 
the  frequent  association  of  face  presentations  with  a  narrowing  of  the 
conjugate. 

Descent  and  Extension. — These  two  movements,  like  descent  and 
flexion  in  vertex  presentations,  are  conjoined — not  distinct  from  one 
another.  At  the  brim,  the  large  fontanelle  is  easily  reached,  while 
the  chin  is  inaccessible.  As  the  vertebral  column  is  situated,  in  face 
presentations,  nearer  to  the  chin  than  the  occiput,  extension  is  ac- 
complished in  obedience  to  the  same  rules  which  produce  flexion  in 
vertex  cases.    With  the  descent  of  the  head  through  the  pelvic  chan- 

*  Statistics  arc  as  yet  not  sufficiently  numerous  to  determine  the  question  as  to  which 
position  actually  occurs  most  frequently.  Dubois  and  Desormeaux  ("  Dietionnaire,"  in 
thirty  volumes,  p.  364)  reported  eighty-five  cases.  Of  these,  in  forty-five  the  chin  was 
turned  to  the  right,  while  in  thirty-eight  it  was  directed  to  the  left.  Dr.  A.  Walther 
(VVinckcl's  "  Berichte,"  Bd.  iii,  p.  312)  reported  from  the  Dresden  Lying-in  Institute  thirty- 
one  cases.  Of  these,  the  chin  was  turned  to  the  left  twenty-one  times,  to  the  right  ten  times. 

f  Duncan,  "Edinburgh  Obstet.  Trans.,"  vol.  ii,  p.  108. 

X  Schroeder,  "  Lehrbuch  der  Geburtshiilfe,"  p.  182.  *  Ahlfeld,  loc.  cit.,  p.  62. 


MECHANISM  OF  LABOR. 


185 


nel,  the  chin  sinks  deeper  and  deeper,  while  the  occiput  is  pushed 
backward  and  pressed  firmly  against  the  dorsal  surface  of  the  child. 
The  degree  of  extension  at  the  different  stages  of  the  descent  is  meas- 
ured by  the  relative  positions  of  the  chin  and  the  large  fontanelle. 

The  engagement  of  the  head  is  usually  slow  and  accomplished  with 
difficulty,  owing  to  the  fact  that 
the  neck  and  posterior  portion 
of  the  head  enter  the  excavation 
at  the  same  time.  The  descent 
of  the  head  is  normally  limited 
by  the  length  of  the  child's  neck, 
as  it  is  only  in  the  case  of  a 
very  small  child,  or  exceptionally 
roomy  pelvis,  that  the  head  and 
upper  portion  of  the  thorax  can 
enter  the  pelvis  simultaneously. 

When  the  face  reaches  the  pel- 
vic floor,  a  slight  degree  of  lateral 
obliquity  is  produced,  the  cheek 
directed  toward  the  j)ubes  advan- 
cing somewhat  more  rapidly  than 
the  one  turned  to  the  sacrum. 

Rotation. — AVhen  the  chin  has 
descended  along  the  lateral  or 
posterior  wall  of  the  pelvis  un- 
til the  thorax  reaches  the  linea 
innominata,  further  progress  is 
only  rendered  possible  when  the 
chin  rotates  forward  and  engages 
beneath  the  arch  of  the  pubes.  ^^^-""^J^^^ons  ""^EibSto 
The  mechanism  of  chin-rotation 

is  the  same  portrayed  in  vertex  presentations.  When  extension  is  com- 
plete, the  chin,  as  the  most  dependent  portion,  glides  downward  and 
forward  upon  the  perinaeum,  and  the  malar  bone  is  pressed  between 
the  pubic  rami.  We  have  seen  already  that  the  pressure  above  the 
pubic  arch  diminishes  from  before  backward,  while  below  it  dimin- 
ishes from  behind  forward.  In  accordance  with  the  mechanical  prin- 
ciple, that  a  body  subjected  to  various  pressures  moves  in  the  direc- 
tion of  least  pressure,  the  chin  or  deeper  portion  turns  to  the  front, 
while  the  cranial  vault  rotates  into  the  hollow  of  the  sacrum.  To 
this  movement  the  unequal  length  of  the  two  extremities  of  the 
lever,  measuring  from  the  malar  bone  to  the  top  of  the  forehead  on 
the  one  side,  and  from  the  malar  bone  to  the  chin  upon  the  other,  con- 
tributes in  an  important  degree.* 

*  Tarnier  et  Chantreuil,  loc.  cit.,  p.  658. 


186 


LABOR. 


Flexion. — After  rotation,  the  chin  emerges  beneath  the  pubic  arch, 
the  shoulders  press  upon  the  base  of  the  skull,  the  perinaeum  becomes 
rounded  by  the  cranial  vault,  and,  finally,  as  the  head  performs  the 
movement  of  flexion  in  obedience  to  the  forward  impulse  imparted  by 
the  perinaeum,  the  chin  rounds  the  symphysis,  while  the  mouth,  the 
nose,  the  brow,  the  vertex,  and  the  occiput  appear  in  succession  at  the 
posterior  commissure  of  the  vulva. 

External  Rotation. — When  the  delivery  of  the  head  is  complete, 
the  shoulders  rotate  into  the  antero-posterior  diameter  of  the  pelvis, 


Fig.  118. —  Engagement  of  the  head  in  face  presentations.    (Tarnier  et  Chantrcuil.) 

the  chin  turning  in  correspondence,  in  right  mento-iliac  positions,  to 
the  right  thigh  ;  in  left  mento-iliac  positions,  to  the  left  thigh. 

Abnormal  Mechanism. 

In  a  foetus  of  small  size,  the  face  may,  when  it  meets  with  slight 
resistance  from  the  perina3um,  be  born  in  any  of  the  pelvic  diame- 
ters. Instances  of  spontaneous  delivery  without  anterior  rotation  of 
the  chin  are,  however,  extremely  rare.  The  egress  of  the  face  in  the 
transverse  diameter  is  possible  in  a  shallow,  rachitic  pelvis,  flattened 
in  the  conjugate  at  the  brim,  and  wide  between  the  ischia  at  the  out' 
let.    The  head  emerges  with  the  chin  resting  upon  one  of  the  ischio- 


MECHANISM  OF  LABOR.  187 


pubic  rami,  around  which  the  rotation  of  the  mento-occipital  diameter 
takes  place.    As  the  movement  is  associated  with  excessive  stretching 


Fig.  119. — Mechanism  of  face  presentations.  (Schultze.) 


of  the  neck,  it  is  evident  that  its  execution  is  favored  by  the  tensile 
condition  of  the  tissues  which  follows  death  of  the  foetus. 


Fio.  120. — Face  presentation,  chin  to  the  rear.  (Hodge.) 


188 


LABOK. 


At  full  term,  the  face  presenting,  spontaneous  delivery  in  mento- 
posterior positions  is  not  practicable.    This  becomes  evident  when  we 

reflect  that,  owing  to  the 
length  of  the  sacral  wall, 
the  chin  can  not  descend 
to  the  fourchette  without 
an  incredible  flattening  of 
the  cranial  vault  and  the 
simultaneous  entrance  of 
the  chest  into  the  pelvic 
cavity.  It  is  claimed,  how- 
ever, that  when  the  head  is 
small  and  compressible  it 
may  stretch  either  the  sa- 
cro-sciatic  ligaments  when 
oblique,  or  the  perinaeum 

Fig.  121. — Outline  of  head  bom  with  face  presenting.        «,  •       ^.^         ^  ■ 

^  *=  alter  passing  the  extremi- 
ty of  the  sacrum,  to  an  extent  sufficient  to  permit  the  descent  of  the 
occiput  beneath  the  pubic  arch,  and  the  conversion  of  the  face  into  a 
vertex-presentation. 

Coi^FIGUEATIOiir  OF  THE  HeAD  I^-  FaCE  PrESEKTATIOJ^-S. 

In  face  presentations,  the  vault  of  the  cranium  is  flattened,  so 
that  the  sagittal  suture  runs  from  fontanelle  to  fontanelle  in  nearly  an 
horizontal  line  ;  the  squa- 
mous portion  of  the  occip- 
ital bone  is  pushed  back- 
ward, while  in  both  the 
occipital  and  frontal  bones 
the  convexity  is  increased. 
As  a  result,  there  is  an 
augmentation  of  the  trans- 
verse, the  occipito-frontal, 
and  occipito-mental  diam- 
eters, while  the  sub-occipi- 
to-bregmatic  is  diminished. 
The  maximum  diameter 
either  corresponds  to  the 
occipito-mental,  or  termi- 
nates posteriorly  at  a  point 
below  the  apex  of  the  oc- 
ciput *  ^^^^  ^"^^  ^^y^  later.  (Budin.) 

The  sero-sanguineous  tumor,  which  forms  upon  the  presenting  part 
as  a  consequence  of  the  diminished  pressure,  occupies  the  lower  portion 

*  Budin,  loc.  ciL,  p.  77. 


MECHANISM  OF  LABOR. 


189 


of  the  malar  region,  and  the  corner  of  the  mouth  (left  mento-iliac 
position,  left  cheek  ;  right  mento-iliac  position,  right  cheek)  in  mento- 
anterior positions,  and  the  npper  portion  of  the  malar  region,  and 
even  the  eye,  in  mento-posterior  positions.  The  integuments  of  the 
cheek  assume  a  blackish-blue  color  ;  the  tumefaction  of  the  lids  is 
such  that  at  birth  the  eyes  are  closed,  and  sanguineous  effusions  are 
found  upon  the  ocular  conjunctiva  ;  and  the  mouth,  when  involved, 
becomes  swollen  and  distorted,  so  that  suction  is  sometimes  interfered 
with  for  several  days  after  birth. 

Diagnosis. — At  a  time  when  a  portion  of  the  head  still  remains 
above  the  level  of  the  pelvic  brim,  it  is  not  infrequently  possible  to 
form  a  diagnosis  from  external  manipulations  alone.  Thus,  by  making 
deep  pressure  with  the  tips  of  the  fingers  above  the  symphysis  pubis, 
the  cranium  may,  under  favorable  circumstances,  be  recognized  upon 
one  side  of  the  pelvis,  together  with  the  sharp  angle  formed  at  the 
neck  between  the  occiput  and  the  dorsum  of  the  foetus.  As  the 
heart  is  heard  with  greatest  distinctness  over  the  anterior  portion  of 
the  chest  in  face  presentations,  confirmatory  evidence  of  the  latter  is 
afforded  by  detecting  the  presence  of  the  fetal  extremities,  and  the 
heart-sounds  upon  the  same,  instead  of,  as  in  vertex  presentations, 
upon  opposite,  sides  of  the  trunk. 

Upon  internal  examination,  the  distinct  peculiarities  are  a  high  po- 
sition of  the  presenting  part,  a  flattening  of  the  vaginal  fornix,  and, 
through  the  intervening  tissues,  the  recognition  of  the  smooth  forehead, 
contrasting  with  the  uneven  surface  of  the  face.  Through  the  dilated 
cervix  the  finger  detects  the  forehead,  the  bridge  of  the  nose,  the  nostrils, 
the  orbits,  the  malar  bones,  the  alveolar  processes  of  the  jaw,  the  mouth, 
and,  when  extension  is  complete,  the  pointed  chin.  Instances  have, 
indeed,  been  recorded  where,  in  advanced  labor,  the  distorted  face  has 
been  confounded  with  the  breech,  the  inexperienced  observer  mistaking 
the  swollen  cheeks  for  the  nates,  the  malar  bones  for  the  ischia,  the  nose 
for  the  tip  of  the  coccyx,  the  oedematous  eyelids  for  the  scrotum,  and 
the  mouth  for  the  anus.  Such  an  error  is  best  avoided  by  deliberation 
in  exploring  the  presenting  part.  With  proper  care  the  smooth  fore- 
head, the  bridge  of  the  nose,  the  hard  orbital  borders,  the  chin,  and 
especially  the  mouth,  through  which  the  jaws  can  be  felt,  afford  suffi- 
cient data  for  a  correct  diagnosis. 

Prognosis. — According  to  the  statistics  of*  Winckel,*  the  mortality 
of  the  children  in  face  presentations  amounted  to  thirteen  per  cent., 
while  that  of  the  mothers  reached  as  high  as  six  per  cent.  Thus, 
though  spontaneous  delivery  is  the  rule  in  face  presentations,  the 
dangers  to  both  mother  and  child  are  considerably  greater  than  in 
vertex  presentations.  The  causes  of  the  less  favorable  prognosis  are 
to  be  looked  for  in  the  increased  peripheral  head  measurements,  which 

*  WiNCKEL,  "  Pathologie  der  Geburtshiilfc,"  p.  89. 


190 


LABOR. 


engage  successively  in  the  different  planes  of  the  obstetric  canal,  and 
consequently  from  the  increased  reciprocal  pressure  exerted  between 
the  head  and  the  soft  parts,  and  partly  from  the  compression  of  the 
veins  of  the  neck  by  the  anterior  wall  of  the  pelvis.  Though  the 
average  length  of  labor  does  not  much  exceed  that  of  normal  presen- 
tations,* the  duration  is  more  readily  affected  by  minor  disturbances, 
such  as  weak  pains,  moderately  contracted  pelves,  and  rigidity  of  the 
obstetric  canal.  At  the  same  time,  the  prolongation  of  labor  in  these 
cases  is  attended  by  more  disastrous  consequences,  and  calls  more 
frequently  for  the  resources  of  art  to  complete  the  delivery. 

Treatment. — The  first  rule  in  the  treatment  of  face  presentations  is 
to  carefully  avoid  prematurely  rupturing  the  membranes.  The  face  is 
ill  adapted  to  serve  the  purpose  of  a  dilator  to  the  cervical  canal,  and 
early  rupture  is  apt  to  be  followed  by  complete  escape  of  the  amniotic 
fluid — an  accident  always  to  be  dreaded,  but  specially  serious  in  face- 
presentations,  where  the  umbilical  cord  is  exposed  to  pressure  between 
the  anterior  surface  of  the  child  and  the  uterine  wall.  Examinations 
made  with  a  view  to  diagnosis  should,  therefore,  be  conducted  with 
great  care,  during  an  interval  between  the  pains,  and  their  repetition 
should  be  avoided  when  the  requisite  information  has  once  been  ob- 
tained. During  the  progress  of  the  first  stage  of  labor,  it  is  recom- 
mended to  place  the  mother  upon  the  side  toward  which  the  chin  of 
the  child  is  turned,  with  a  view  of  favoring  extension  and  rotation. 

Because  of  the  uncertainties  of  the  prognosis  in  face  presentav 
tions,  many  manoeuvres  have  been  proposed  for  the  conversion  of  the 
latter  into  normal  presentations.  The  manipulations  chiefly  recom- 
mended consist  of  either  pushing  up  the  face,  or  drawing  down  the 
occiput,  by  the  fingers  passed  through  the  cervical  canal.  Though 
occasionally  successful,  they  have  been  discountenanced  by  most  ob- 
stetric writers,  because  experience  has  shown  the  results  to  be  by  no 
means  commensurate  with  the  dangers  incurred.  Schatz  f  has,  how- 
ever, suggested  a  rational  plan  for  reducing  the  extended  head  by 
external  manipulations  only,  which  avoids  the  objections  to  the  earlier 
methods.  His  manoeuvre  consists  in  restoring  the  normal  attitude  of 
the  body  by  flexing  the  trunk,  and  leaving  the  head  to  resume  spon- 
taneously its  proper  position  as  it  sinks  into  the  pelvis.  It  is  per- 
formed by  seizing  the  shoulder  and  breast  with  the  hand  through  the 
abdominal  walls  ;  then  lifting  the  chest  upward  and  pressing  it  back- 
ward, at  the  same  time  steadying  or  raising  the  breech  with  the  other 
hand  applied  near  the  fundus,  so  as  to  make  the  long  axis  of  the  child 
conform  to  that  of  the  uterus,  and,  finally,  pressing  the  breech  directly 
downward.    As  the  child  is  raised,  the  occiput  is  allowed  to  descend, 

*  Waltiier,  Winckel's  "Bcriclitc,"  Bd.  iii,  p.  315. 

f  Schatz,  "  Die  Umwandlung  von  Gcsichtslage,"  etc.,  "  Arch.  f.  Gynack.,"  Bd.  v,  p. 
313. 


I 


MECHANISM  OF  LABOR. 


191 


and  then,  as  the  body  is  bent  forward,  head-flexion  is  produced  by  the 
resistance  of  the  side-walls  of  the  pelvis.  Schatz  illustrates  these 
moTements  by  the  accompanying  diagrams.    If,  owning  to  its  elevation. 


Figs.  123-125.— Diagrams  showing  Schatz's  method  of  couvcrthig  uce  presentations  into 

vertex  presentations. 

the  head  tends  to  move  to  one  side  when  backward  pressure  is  made 
upon  the  chest,  the  place  of  the  pelvic  wall  may  be  supplied  by  ex- 
ternal pressure  exerted  by  an  assistant.  The  time  for  attemjoting  this 
manipulation  is  previous  to  the  rupture  of  the  membranes.  The 
requisites  for  success  are  experience  in  mapping  out  the  fetal  out- 
lines by  external  palpation,  and  the  absence  of  abdominal  and  uterine 
irritability.  After  rupture  of  the  membranes,  great  care  must  be 
exercised  in  vaginal  explorations,  to  avoid  injuring  the  eyes,  or  exciting 
premature  respiratory  movements  by  allowing  air  to  enter  the  mouth. 

If  the  chin  remains  persistently  directed  to  the  rear,  rotation  may 
sometimes  be  promoted  by  either  pressing  forAvard  with  two  fingers 
upon  the  lower  jaw,  or  by  pushing  the  forehead  backward  and  upward, 
to  produce  a  deep  descent  of  the  chin.  To  be  effective,  either  ma- 
nipulation should  be  executed  during  a  pain.  Hodge  advocates  the 
vectis,  and  others  a  blade  of  the  forceps,  as  of  use  in  correcting  mento- 
posterior positions.  As  a  rule,  however,  good  pains  and  complete  ex- 
tension are  the  conditions  most  likely  to  effect  the  forward  movement 
of  the  chin.  It  is  practically  of  importance  to  bear  in  mind  that 
tardy  rotation  is  characteristic  of  face  presentations.  The  treatment, 
in  cases  where  all  measures  prove  ineffective  to  secure  a  favorable 
change  of  position,  and  dangers  accrue  from  delay  to  either  mother  or 
child,  belongs  to  the  domain  of  operative  midwifery. 

During  head-expulsion  caution  must  be  used  in  supporting  the 
perinaeum,  in  order  not  to  injure  the  neck  by  too  strong  forward 
pressure  against  the  anterior  wall  of  the  pelvis. 


192 


LABOR. 


It  is  safe  to  assure  the  bystanders  that  the  distortion  of  the  face 
after  delivery  will  disappear  spontaneously  in  the  course  of  from  twen- 
ty-four to  forty-eight  hours. 

Brow  Presentations. 

In  brow  presentations  the  head  occupies  a  position  intermediate 
between  flexion  and  extension.  Of  necessity  every  face  presentation 
has  become  such  after  first  passing  through  the  frontal  stage.  A  tem- 
porary dip  of  the  large  fontanelle  in  the  earlier  period  of  labor  is  by 
no  means  uncommon.  With  the  advance  of  the  head,  however,  the 
resistance  encountered  usually  causes  the  complete  descent  of  either 
the  chin  or  the  occiput.  The  causes  of  brow  presentations  are,  in  the 
main,  the  same  as  those  given  for  presentations  of  the  face,  viz.,  ob- 
liquity of  the  uterus  and  foetus,  enlargements  of  the  neck  and  thorax, 
contracted  pelvis,  and  excessive  mobility  of  the  foetus. 

The  diagnosis  is  made  by  recognizing  the  apex  of  the  forehead 
in  the  pelvic  canal,  with  the  orbits  and  the  root  of  the  nose  upon  one 
side,  and  the  large  fontanelle  and  parietal  bones  upon  the  other.  At 
the  brim  the  frontal  suture  is  usually  transverse,  but  becomes  oblique 
m  its  progress  toward  the  pelvic  outlet. 

A  small  head  may  pass  through  a  roomy  pelvis,  the  brow  present- 
ing, without  injury  to  either  mother  or  child.  In  the  mechanism  of 
delivery  the  forehead  turns  to  the  front  and  appears  at  the  vulva,  the 
upper  maxilla  resting  against  the  symphysis,  and  the  cranium  lying  in 
the  hollow  of  the  sacrum  and  upon  the  perinaeum.  The  exit  is  accom- 
plished by  the  cranial  vault 
first  sweeping  forward  over 
the  perinseum  ;  the  upper 
jaw,  the  mouth,  and  the 
chin  afterward  making  their 
appearance  beneath  the 
symphysis  pubis. 

Sometimes,  though  usu- 
ally only  when  the  forceps 
is  used,  the  head  may  be 
delivered  in  the  transverse 
diameter,  in  which  case  the 
superior  maxilla  finds  a 
point  of  support  against  one 
ischio-pubic  ramus,  while 
the  cranium  rotates  trans^ 
versely  through  the  vulva.  When  the  face  turns  posteriorly,  deliverj 
of  a  living  child  is  scarcely  possible. 

The  configuration  of  the  head  is  very  striking.  The  swelling  of 
the  integuments  extends  from  the  root  of  the  nose  to  the  upper  angle 


Fig.  126.— Outline  of  head  after  delivery,  the  brow 
presenting.  (Budin.) 


MECHANISM  OF  LABOR. 


193 


of  the  large  fontanelle.  Tlie  forehead  is  nearly  perpendicular,  while 
the  parietal  and  occipital  bones  form  a  slope  which  inclines  downward 
and  backward.  The  mento-frontal  and  sub-occipito-frontal  diameters 
are  increased,  while  the  distance  between  the  chin  and  a  point  in  the 
sagittal  suture  anterior  to  the  occiput  is  diminished.  These  changes 
impart  to  the  head  a  triangular  shape.  The  peculiar  formation  is  ex- 
plained by  the  compression  of  the  occiput  between  the  pelvis  and  the 
dorsal  surface  of  the  child,  and  the  compensatory  elongation  which 
takes  place  in  the  direction  of  the  forehead. 

The  prognosis  is  less  favorable  than  in  vertex  presentations,  but  is 
by  no  means  so  sinister  as  is  popularly  supposed.  Many  cases  of 
original  brow  presentations  become  converted  into  face  or  vertex  pres- 


Fio.  127.— Brow  presentation,  subsequently  converted  into  that  of  the  face.*  (Maternity 

Hospital.) 

entations  during  the  progress  of  labor ;  many  are  delivered  spontane- 
ously or  by  the  aid  of  the  forceps.    Craniotomy  is  rarely  called  for. 

Ahlfeld  ("Die  Entstehimg  Steiss-  und  Gesichtslagen  ")  furnishes  twenty- 
six  cases  in  which  the  result  to  both  mother  and  child  is  given.  Feitsch  ("  KHnik 
der  alltaglichen  geburt?liulflichen  Operationen,"  p.  46)  gives  the  histories  of  seven 
cases,  and  Budin-  ("  Tete  du  Foetus,"  p.  53)  the  history  of  one  case.  In  the  thirty- 
four  deliveries  there  were  two  maternal  deaths;  in  one  of  the  fatal  cases  coxal'gic 
oblique  pelvis  existed  as  a  complication.  In  the  other  the  brow  spontaneously 
changed  into  a  face  presentation.  Tiierc  were  ten  spontaneous  deliveries,  the 
brow  presenting,  with  four  dead  children,  but  one  died  previous  to  labor:  There 
were  ten  cases  of  spontancouo  delivery  in  which  the  brow  during  delivery  be- 
came converted  into  either  a  face  or  vertex  presentation.  Of  these  one  child  died.. 
*  Recovery  of  both  mother  and  child. 

13 


194 


LABOR. 


Fourteen  children  were  extracted  with  the  forceps,  nine  with  the  brow  present- 
ing, of  which  two  were  dead,  one  from  prolapsed  funis,  and  one  which  had  died 
before  labor ;  five,  after  conversion  into  face  or  vertex  presentations,  with  no 
deaths.  Thus,  of  the  thirty-four  children,  there  were  seven  deaths,  but  of  these 
four  only  could  be  attributed  to  the  presentation. 

From  the  foregoing,  it  is  evident  that  the  duties  of  the  accoucheur, 
in  the  presence  of  brow  presentation,  should  be  confined  to  efforts  to| 
direct  the  labor  to  a  favorable  termination  by  one  of  the  paths  indi- 
cated by  Nature.  At  the  brim,  previous  to  engagement,  the  dip  of 
the  anterior  fontanelle  is  often  temporary,  in  many  cases  simply  sig- 
nifying a  narrowing  in  the  upper  conjugate.  For  this  reason  it  is 
evident  that  version,  so  frequently  recommended  with  a  view  to  the 
substitution  of  diameters  more  conformable  to  those  of  the  pelvis,  is 
to  be  regarded  as  of  questionable  value.  Early  in  labor  it  does  not 
better  the  prognosis,  while  at  an  advanced  stage,  when  self-correction 
is  no  longer  probable,  the  difficulties  of  its  execution  exclude  it  from 
the  list  of  practicable  measures. 

Manual  attempts  to  convert  a  brow  presentation  into  one  of  the 
face  or  vertex  possess  more  legitimate  claims  to  favor.  The  method 
of  Baudelocque  consists  in  seizing  the  head  with  the  entire  hand 
introduced  into  the  vagina,  lifting  it  to  the  brim,  and  then  drawing 
the  occiput  downward  with  the  fingers  until  flexion  becomes  com- 
plete. The  procedure  was  bitterly  opposed  by  Chailly,*  who  urged 
against  it,  in  addition  to  the  frequency  of  failure,  the  dangers  of  uter- 
ine rupture,  of  prolapse  of  the  cord,  and  the  inconveniences  arising 
from  the  early  evacuation  of  the  amniotic  fluid.  There  is  no  question 
of  successes  by  this  measure,  but  the  concurrent  risks  ought  to  limit 
its  employment  to  cases  of  absolute  necessity.  Thus,  it  would  be  proper 
to  make  the  attempt  when  brow  presentations  complicate  delivery  in 
justo-minor  pelvis,  or  in  persistent  mento-posterior  positions,  as  in 
these  cases  craniotomy  is  the  only  alternative.  Complete  anaesthesia 
facilitates  reduction  ;  while  elevating  the  head,  firm  counter-pressure 
should  be  made  at  the  fundus  uteri,  f 

Occasionally  the  conversion  of  the  brow  into  a  vertex  or  face  pres- 
entation may  be  effected  by  pressure  exerted  during  a  pain  upon  re- 
spectively the  occipital  or  frontal  extremity  of  the  head.  In  bringing 
down  the  vertex,  the  movement  should  be  aided  by  external  pressure 
made  with  the  disengaged  hand  above  the  brim  of  the  pelvis.  When 
a  face  presentation  is  desired,  the  woman  should  be  made  to  lie  during 
labor  upon  the  side  to  which  the  child's  abdomen  is  directed,  and  upon 
the  side  to  which  the  back  is  turned  when  the  descent  of  the  vertex  is 
aimed  at. 

*  Chailly-Honore,  "  Trait6  pratique  dcs  accouchemcnts,"  p.  783. 
f  Vide  Parry,  '*  On  the  Use  of  the  Hand  to  correct  Unfavorable  Presentations,"  etc., 
"Am.  Jour,  of  Obstct.,"  vol.  vlii,  p.  138. 


MECHANISM  OF  LABOR. 


195 


Schatz  *  recommends,  with  the  view  to  the  production  of  a  face 
presentation,  the  introduction  of  two  fingers  into  the  child's  mouth, 
and  making  traction  on  the  superior  maxilla. 

When  the  head  shows  a  disposition  to  revert  to  its  original  position 
so  soon  as  pressure  or  traction  is  suspended,  the  forceps  should  be 
applied,  and  traction  made  in  such  a  manner  after  reposition  as  to 
hold  the  head  in  the  direction  sought  for. 

In  case  the  brow  presentation  is  irreducible,  the  labor  should  be 
allowed  to  continue  as  long  as  compatible  with  the  safety  of  the 
mother.  Owing  to  its  plasticity,  the  head  often  adapts  itself  in  the 
most  surprising  manner  to  the  unfavorable  diameters  of  the  pelvis,  so 
that,  even  when  spontaneous  delivery  fails  to  take  place,  the  forceps  be- 
comes available.  In  mento-posterior  positions,  etforts  should  be  made 
with  the  fingers,  or  the  vectis,  to  rotate  the  chin  forward.  In  fixed 
mento-posterior  positions,  the  use  of  the  forceps  is  impossible,  and  the 
conversion  of  the  brow  into  a  face  presentation  does  not  lessen  the 
mechanical  difficulties  of  delivery.  The  only  artifice  by  which  the 
life  of  the  child  can  be  saved  consists  in  bringing  down  the  occiput, 
and  producing  a  vertex  presentation.  Failing  in  this  manoeuvre, 
craniotomy  becomes  inevitable.  In  all  cases  of  brow  presentation,  if 
the  child  is  dead,  craniotomy  is  indicated  in  i>he  interest  of  the  mother. 

Breech  Presei^^tatioks. 

In  breech  presentations  the  attitude  of  the  child  is  primarily 
the  same  as  in  those  of  the  vertex,  though,  owing  to  a  variety  of 
causes,  such  as  voluntary  or  reflex  movements  and  the  action  of 
gravity,  especially  after  rupture  of  the  membranes,  the  extremities 
may  advance  in  front  of  the  breech,  and  give  rise  secondarily  to 
presentations  of  the  foot  or  knee.  Sometimes  one  extremity  may 
become  prolapsed,  while  the  other  is  retained  in  its  normal  position  ; 
again,  it  may  happen  that,  after  the  rupture  of  the  membranes,  the 
feet,  which  had  previously  been  in  close  proximity  to  the  breech,  are 
pushed  upward,  so  that  the  limbs  become  extended  parallel  to  the 
anterior  surface  of  the  child's  body.  None  of  these  changes,  how- 
ever, materially  affect  the  mechanism  of  delivery. 

Pinard  f  found  in  100,000  cases  of  confinement  3,301  presentations 
by  the  breech,  or  in  the  proportion  of  one  to  thirty,  but,  excluding 
premature  births,  the  proportion  was  reduced  to  one  in  sixty-two. 

Causes. — The  causes  of  breech  presentations  are  to  be  sought  for 
mainly  in  the  absence  of  the  conditions  which  ordinarily  determine 
the  presentations  of  the  head,  or  which  interfere  with  the  fixation 
of  the  fcetus.    Thus,  the  production  of  breech  presentations  is  favored 

*  ScHATZ,  "Die  Umwandlung  von  Gesichtslage  zu  Hinterbauptslage,"  etc.,  "Arch.  f. 
Gynaek.,"  Bd.  v,  p.  328. 

f  Tarnieu  et  Chantreuil,  *'  Traite  de  Part  des  ac,"  p.  454. 


196 


LABOR. 


by  an  excess  of  amniotic  fluid,  by  lax  uterine  walls,  and  by  contrac- 
tions of  the  pelvis.  They  are  more  common  in  multiparae  than  in 
primiparse.  Of  the  3,301  cases  collected  by  Pinard,  there  were  1,347 
primiparse  and  1,954  multiparse,  though  the  entire  number  was  nearly 
equally  divided  between  the  two  classes.*  Finally,  they  occur  with 
greatest  frequency  of  all  in  twin  pregnancies,  and  during  the  expul- 
sion of  premature  and  dead  children.  Of  32,264  children  from  the 
statistics  of  Hegar  and  Spiegelberg,f  910  were  the  product  of  multiple 
pregnancies,  and  659  were  premature.  Of  the  former,  227,  or  25  per 
cent.,  and  of  the  latter  148,  or  22*4  per  cent.,  were  delivered  by  the 
breech,  though  we  have  seen  that  the  ratio  of  breech  presentations 


Fig.  128. — Presentation  of  the  breech.  Left  dorso-anterior  position.  (Tarnier  et  Chantrcuil.) 

to  the  entire  number  of  births  does  not  exceed  the  proportion  of  one 
to  thirty. 

Diagnosis. — By  external  palpation  the  recognition  of  the  head  at 
the  fundus  uteri  furnishes  the  chief  diagnostic  sign.  Upon  vaginal 
examination,  the  presenting  part,  as  in  face  presentations,  is  usually 
high  up,  and  reached  with  difficulty.  The  bag  of  membranes  is  apt 
to  be  of  large  size,  owing  to  the  imperfect  closure  of  the  lower  uterine 
segment  by  tlie  small  breech,  often  descending  through  the  canal, 
where  the  cervix  is  rigid,  in  the  form  of  an  elongated  pouch.  Through 
the  membranes,  upon  pressing  the  foetus  downward  during  the  inter- 


*  Vide  Tarnier  et  Ciiantreuil,  p.  455. 


f  SriEGELEERG,  loC.  c'lL^  p.  17L 


MECHANISM  OF  LABOR. 


197 


val  between  the  pains,  the  breech  is  felt  as  a  soft,  irregular  body,  and 
with  care  it  is  possible  to  recognize  the  coccyx,  the  sacrum,  the  ilia, 
and  sometimes  to  feel  tapping  movements  from  the  feet.  After 
rupture,  the  nates,  the  cleft  between  the  nates,  in  boys  the  scrotum, 
the  anus,  the  feet  when  accessible,  the  coccyx,  the  sacrum,  and  the 
ilia,  furnish  the  necessary  data  for  an  exact  diagnosis.  The  pressure 
of  the  uterus  upon  the  breech  frequently  occasions  an  evacuation  of 
meconium.  The  latter  is  thick  and  consistent,  thereby  differing  from 
the  meconium  passed  in  vertex  cases  by  a  dying  foetus,  which  is 
ordinarily  thin  from  admixture  of  amniotic  fluid.  When  the  nates 
are  much  swollen  they  may  be  confounded  with  the  cheeks  in  a  face 
presentation,  an  error,  however,  easy  to  avoid,  if  the  examination  be 
made  with  deliberation,  and  the  principal  points  of  difference  between 
breech  and  face  already  given  {vide  ^^Face  Presentations,"  p.  189)  are 
borne  in  mind. 

The  foot,  as  compared  with  the  hand,  is  longer  and  narrower,  the 
toes  are  shorter,  of  nearly  equal  length,  and  continuous  in  a  straight 
line  with  the  sole,  the  ankle-joint  is  less  flexible  than  the  wrist,  and  is 
distinguished  by  the  malleoli  and  the  pointed  heel.  As  the  outer  bor- 
der of  the  foot  is  thin  and  rounded,  while  the  inner  edge  is  thick  and 
hollowed,  it  becomes  possible  to  recognize  which  of  the  feet  is  under 
examination.  j 

The  knee  is  distinguished  from  the  elbow  by  its  larger  size,  by  the 
patella,  and  by  the  spine  of  the  tibia. 

The  Mechanism  of  Breech  Presentations. — The  position  in  breech 
presentations  is  defined  by  the  direction  of  the  back.  Thus,  we  have 
right  and  left  dorsal  positions.  Usually  the  hips  occupy  one  of  the 
oblique  diameters  of  the  pelvis.  According,  therefore,  as  the  back  is 
turned  anteriorly  or  posteriorly,  we  distinguish  right  and  left  dorso- 
anterior  and  dorso-posterior  positions. 

The  cervix  dilates  slowly,  especially  when  the  feet  are  in  close 
proximity  to  the  breech,  and  increase  the  bulk  of  the  presenting  part. 
The  latter  is  pressed  downward  into  the  pelvis  until  the  perineal  floor 
is  reached.  Here,  owing  to  the  shortness  of  the  pubic  wall,  the  ante- 
rior hip  is  felt  with  great  distinctness,  while  the  cleft  of  the  nates  lies 
near  the  curved  sacrlim.  These  anatomical  relations  give  rise  to  the 
impression  of  an  exaggerated  degree  of  lateral  obliquity.  At  the  peri- 
naeum  the  breech  glides  forward  and  rotates  upon  its  long  axis,  so  that 
the  bis-iliac  diameter  nearly  corresponds  to  the  lower  conjugate.  In 
the  movement  of  rotation,  it  is  always  the  anterior-lying  hip,  irrespec- 
tive of  the  position  of  the  trunk,  which  moves  to  the  front.  At  the 
outlet  one  hip  engages  beneath  the  arch  of  the  pubes,  the  other  rests 
upon  the  coccyx  and  perinseum,  while  the  sacrum  is  directed  toward 
the  tuber  ischii.  As  the  shoulders  enter  the  pelvis  in  an  oblique 
diameter,  the  trunk  of  the  child  becomes  somewhat  twisted  by  the 


198 


LABOR. 


rotation  of  the  breech.  The  anterior  buttock  makes  its  appearance  at 
the  vulva,  while  the  posterior  distends  the  perinseum.  As  rotation  is 
rarely  complete,  the  forward  trochanter  usually  finds  its  point  of  sup- 
port against  the  nearest  ischio-pubic  ramus.  During  the  advance  of 
the  breech,  the  lumbar  region  undergoes  a  certain  amount  of  lateral 
flexion,  owing  to  the  forward  movement  imparted  to  the  posterior  hip 
by  the  coccyx  and  elastic  perinseum.  The  degree  of  flexion  is,  how- 
ever, limited  by  the  rigidity  of  the  lumbar  portion  of  the  vertebral 
column.  When  the  posterior  trochanter  reaches  the  commissure  of 
the  vulva,  the  perinseum  retracts,  and  in  gliding  backward  directs  the 
breech  still  farther  to  the  front. 


Fig.  129. — Illustration  showing  lateral  inflexion  of  the  trunk  during  delivery  of  the  breech. 

After  delivery,  the  breech  rotates  into  the  oblique  diameter  it  had 
originally  occupied,  this  external  rotation  bringing  the  transverse 
diameter  of  the  hips  into  correspondence  with  that  of  the  shoulders. 
The  uterine  contractions  continuing,  the  abdomen  and  base  of  the 
thorax  slowly  make  their  appearance  ;  the  thighs  are  then  delivered, 
and  the  arms,  folded  upon  the  upper  portion  of  the  thorax,  emerge 
from  the  vulva.  The  shoulders,  which  enter  the  pelvis  in  an  oblique 
diameter,  are  delivered  in  the  conjugate,  the  anterior  shoulder  resting 
beneath  the  pubic  arch,  while  the  posterior  shoulder  sweeps  over  the 
perinaeum. 

The  head  enters  the  pelvis  in  an  oblique  diameter,  with  the  chin 
flexed  upon  the  thorax.  The  expulsive  efforts  as  the  chin  reaches  the 
perinaeum  arc  followed  by  the  rotation  of  the  occiput  to  the  pubes,  and 


MECHANISM  OF  LABOR. 


199 


of  the  face  into  the  hollow  of  the  sacrum.  At  the  outlet  the  neck  is 
supported  by  the  arch  of  the  pubes,  the  face  rests  upon  the  perinteum, 
and  the  large  fontanelle  is  felt  at  the  coccyx.  Under  the  influence  of 
pressure  from  the  abdomen,  the  brow  sinks  deeper  and  deeper,  and  is 
pushed  by  the  soft  parts  of  the  pelvic  floor  still  closer  to  the  thorax. 
The  occiput  then  revolves  beneath  the  jDubic  arch,  and  the  chin,  the 
mouth,  the  nose,  the  brow,  the  large  fontanelle,  and  finally  the  occiput, 
appear  in  succession  at  the  commissure  of  the  vulva. 

Irregularities  in  the  Mechanism  of  Breech  Presentations.— Though 
it  is  by  no  means  rare  for  the  breech  to  enter  the  pelvis  with  the 
sacrum  turned  to  the  sacro-iliac  synchondrosis,  the  rotation,  begun 
with  the  passage  of  the  hips  through  the  vulva,  usually  continues  in 
the  same  direction  until  the  back  revolves  to  the  front ;  or,  after  a  first 
slight  retrograde  movement,  the  rotation  forward  takes  place  as  the 
shoulders  engage  at  the  outlet.  Still,  cases  do  sometimes  occur  in 
which  the  back  remains  posterior  during  the  whole  period  occupied  by 
the  expulsion  of  the  trunk,  and  in  which  consequently  the  head  enters 
the  pelvis  with  the  face  directed  to  the  pubes.  Even  here,  however, 
it  is  very  common  for  the  occiput  to  eventually  rotate  forward,  and  for 
delivery  to  follow  in  the  ordinary  manner.  Should,  on  the  contrary, 
the  occiput  remain  in  the  hollow  of  the  sacrum,  spontaneous  delivery 
may  occur  in  either  of  two  ways  :  1.  Wlien  no  tractions  have  been 
made  upon  the  extremities,  the  head  reaches  the  outlet  with  the  chin 
well  flexed,  the  neck  resting  upon  the  commissure  of  the  vulva,  and 
the  brow  braced  against  the  arch  of  the  pubes.  The  birth  of  the  head 
is  then  accomplished,  as  the  neck  pushes  back  the  perinaeum,  by  the 
successive  descent  of  the  face,  the  cranial  vault,  and  the  occiput. 
With  a  rigid  perinaeum,  or  an  immovable  coccyx,  the  considerable 
degree  of  flexion  which  this  movement  necessitates  may  be  rendered 
impossible.  2.  If,  during  the  transit  of  the  head  through  the  pelvis, 
extension  occurs,  the  chin  may  be  arrested  at  or  above  the  symphysis 
pubis.  In  this  position  pressure  from  above  pushes  back  the  brow, 
so  that  the  face  looks  upward,  and  the  occiput  is  turned  to  the  bottom 
of  the  pelvic  excavation.  During  delivery  the  occiput  glides  over  the 
perinaeum  to  the  fourchette,  and  the  small  fontanelle,  the  cranial  vault, 
and  the  face  escape  in  succession  through  the  vulva.  It  is  only  possi- 
ble for  this  method  of  delivery  to  take  place  spontaneously  when  either 
the  head  is  small  or  the  pelvis  roomy,  and  the  soft  parts  are  devoid  of 
rigidity.  In  artificial  extraction  of  the  head,  it  is  proper  to  bear  in 
mind  and  to  imitate  the  natural  order  in  expulsion. 

In  presentations  of  the  foot  and  knee,  the  breech,  if  of  small  size, 
may  pass  the  vulva  in  an  oblique  or  transverse  diameter,  rotation  fol- 
lowing later  during  the  passage  of  the  trunk. 

Excessive  rotation  is  not  uncommon,  both  head  and  trunk  some- 
times describing  a  half-circle.    This  occurrence  is  most  frequently  ob- 


200 


LABOR. 


served  in  cases  where  the  posterior  extremity  presents,  while  the  ante- 
rior buttock  is  caught  above  the  pubic  wall,  the  prolapsed  limb  then 
rotating,  as  a  rule,  to  the  front.* 

The  Configuration  of  the  FiBtus  in  Breech  Deliveries. — During  the 
descent  of  the  child  through  the  genital  canal,  more  or  less  swelling  is 
developed  upon  that  portion  of  the  presenting  part  which  is  subjected 
to  diminished  pressure.  This  swelling  varies,  according  to  the  du- 
ration of  labor,  from  a  slight  oedema  to  a  large,  intensely  discolored 
tumor.  It  is  usually  seated  upon  the  anterior  buttock,  but  often  in- 
vades the  genital  organs,  especially  the  scrotum,  which  at  birth  may 
present  a  bluish-black  color,  and  be  of  double  the  usual  size.  The  ex- 
tremities, when  near  the  breech,  may  also  show  signs  of  discoloration. 

The  head  has  usually  a  characteristic  round  shape.  This  is  due, 
according  to  Spiegelberg,f  to  the  pressure  exerted  by  the  genital  canal 
upon  the  circumference  of  the  head,  while,  at  the  same  time,  with  the 
absence  of  pressure  from  above,  there  is  produced  an  increase  in  the 

convexity  of  the  cranial 
vault.  Two  cases  reported 
by  Hecker,  I  in  which  the 
length  of  the  occiput  was 
comparable  to  that  found 
in  face  i)resentations, 
show,  however,  that  the 
original  shape  of  the  head 
counts  for  something  in 
the  appearances  presented 
after  delivery. 
'  Prognosis— As  regards 
the  mother,  the  prognosis 
in  uncomplicated  cases 
does  not  differ  materially 

Fig.  130.— Showing  shape  of  head  in  breech  presenta-    ^^'^"^  Vertex  cases. 

tions.  (Budin.)  Where  manual  extraction 

becomes  necessary,  there 
is  always,  however,  increased  danger  of  lacerating — 1.  The  cervix  ;  2. 
The  perinaBum. 

Lacerations  of  the  cervix  are  apt  to  follow  attempts  to  drag  the 
after-coming  head  through  an  imperfectly  dilated  cervix.  The  prog- 
nosis is  more  favorable,  therefore,  in  cases  where  the  membranes  do 
not  rupture  until  after  dilatation  is  completed.  It  is  also  better  in 
pelvic  presentations,  where  the  bulk  of  the  breech  is  increased  by  the 
addition  of  the  extremities.    In  footling  cases,  when  the  membranes 

*  Vide  KusTNER,  "Die  Steiss-  und  Fiisslagcn,"  p.  21. 

\  Spiegelberg,  loc.  cit.,  p.  176. 

X  IIecker,  "  Arch.  f.  Gynack.,"  Bd.  xi,  p.  348. 


MECHANISM  OF  LABOR. 


201 


rupture  prematurely,  the  smaller  size  of  the  pelvis  and  its  rapid  de- 
scent through  the  cervix  imperfectly  prepare  the  way  for  the  subse- 
quent passage  of  the  head.  A  stricture  is,  therefore,  liable  to  form 
about  the  neck  of  the  child,  and,  as  the  spasm  does  not  yield  to  force, 
the  result  of  violent  tractions  is  to  sacrifice  the  integrity  of  the  cervix, 
the  extent  of  the  laceration  being  proportioned  to  the  power  exerted. 

Lacerations  of  the  perinseum  occur  where  with  rigidity  of  the  tis- 
sues it  becomes  necessary  to  introduce  the  hand  to  release  the  arms, 
or  the  interest  of  the  child  demands  the  speedy  delivery  of  the  head. 

The  prognosis  for  the  child  is,  on  the  other  hand,  extremely  unfavor- 
able. According  to  the  statistics  of  Dubois,*  the  mortality  in  full- 
term  children  is  as  one  to  eleven,  while  in  vertex  presentations  the 
proportion  is  as  one  to  fifty.  The  chief  cause  of  this  large  death-rate 
is  the  pressure  to  which  the  cord  is  subjected  between  the  child  and 
the  surface  of  the  utero-vaginal  canal,  especially  after  the  navel  appears 
at  the  vulva.  The  pressure  is  exerted  principally  at  the  orifices  of  the 
uterus  and  the  vagina,  and  is  raised  to  the  point  of  greatest  danger 
after  the  head  has  become  engaged  in  the  pelvis.  Other  sources  of 
peril  arise  from  prolapse  of  the  funis  and  the  coiling  of  the  latter 
around  the  body  of  the  child,  and  from  the  complete  escape  of  the 
amniotic  fluid  in  premature  rupture  of  the  membranes. 

Treatment. — Early  in  labor,  with  the  membranes  intact,  it  is  desir- 
able, in  consideration  of  the  unfavorable  prognosis  for  the  child,  to 
try  and  perform  cephalic  version  by  external  manipulations.  In  case 
of  failure  to  bring  down  the  head,  pains  should  be  taken  to  preserve 
the  membranes  until  dilatation  is  completed.  To  this  end  unneces- 
sary examinations  should  be  avoided,  the  patient  should  be  placed  upon 
her  side  and  cautioned  not  to  strain,  and,  when  the  membranes  tend 
to  form  an  elongated  pouch,  counter-pressure  may  be  employed  by 
means  of  a  moderately  distended  Barnes's  dilator  introduced  into  the 
vagina.  After  rupture  of  the  membranes  it  is  best  to  remain  passive. 
In  the  interest  of  the  child,  it  is  desirable  that  the  expulsion  of  the 
trunk  should  take  place  slowly.  Bringing  down  an  extremity,  as  a 
prophylactic  measure  in  order  to  secure  a  good  handle  in  case  of  sub- 
sequent delay,  is  a  questionable  procedure.  By  this  manoeuvre  a  path 
is  opened  for  the  descent  of  the  cord,  and  the  mechanism  of  delivery  is 
disturbed.  When  the  hips  appear  at  the  vulva,  the  attending  physi- 
cian should  be  ready  to  extract  in  case  of  emergency.  Tiie  patient 
should,  therefore,  if  lying  upon  the  left  side,  be  brought  near  the  edge 
of  the  bed  ;  if  upon  the  back,  she  should  be  placed  across  the  bed  with 
the  hips  well  over  the  edge.  She  should  be  instructed  to  bear  down 
during  the  pains.  The  lateral  flexion  of  the  lumbar  portion  of  the 
trunk  should  be  sustained  by  the  hand  applied  to  the  perinseum.  The 
trunk,  as  it  advances  through  the  vulva,  should  be  wrapped  in  a  warm 
*  Dubois,  "  Mem.  de  I'Acad.  Roy.  dc  j\I6d.,"  vol.  iii,  p.  450. 


202 


LABOR. 


cloth  and  raised  upward.  When  the  cord  appears,  it  should  be  drawn 
gently  downward  in  the  direction  of  one  of  the  recesses  to  the  side  of 
the  promontory  ;  in  case  the  cord  passes  between  the  thighs  of  the 
child,  it  should  be  released  by  slipping  it  over  one  hip.  From  this 
time  on,  the  pulsations  of  the  cord  should  be  carefully  watched,  and, 
in  case  of  failing  strength,  extraction  should  be  resorted  to. 

With  one  hand  the  physician  now  supports  the  body  of  the  child, 
while  with  the  other  he  should  make  sustained  and  gradually  increas- 
ing pressure  upon  the  fundus  uteri.  The  patient  should  be  exhorted 
to  strain,  and  bring  into  play  all  the  auxiliary  muscles  concerned  in 
expulsion.  During  the  passage  of  the  arms,  the  lateral  flexion  of  the 
body  should  be  promoted  by  raising  the  hips  and  supporting  the  peri- 
ngeum.  After  the  engagement  of  the  head,  it  is  desirable,  if  possible, 
to  commit  to  the  hands  of  a  skilled  assistant  the  maintenance  of  the 
supra-pubic  pressure.  When  the  face  reaches  the  coccyx,  the  physi- 
cian should  raise  the  body  of  the  child  toward  the  abdomen  of  the 
mother.  By  this  manoeuvre  the  occiput  is  pushed  upward  by  the 
pubic  wall,  and  the  chin  brought  forward  to  the  vulva.  The  delivery 
of  the  head  is  then  speedily  accomplished  by  pressing  the  forehead 
forward  with  two  fingers  applied  to  the  perinseum  in  front  of  the  coc- 
cyx, or  introduced  into  the  rectum.  By  then  keeping  the  head  flexed, 
lacerations  of  the  perinaeum  are  best  avoided. 

When  the  occiput  is  turned  posteriorly,  the  body  should  be  raised 
if  the  chin  is  arrested  at  the  symphysis,  and  depressed  when  flexion  is 
complete. 


CHAPTEE  XL 

CONDUCT  OF  NORMAL  LABOR.  ' 

Preliminary  preparations. — Examination  of  the  patient.- — Management  of  the  first  stage. 
—  Management  of  the  second  stage. — Preservation  of  the  perinaeum. — Delivery  of  the 
shoulders. — Tying  the  cord. — Third  or  placental  stage. — Care  of  patient  after  deliv- 
ery.— Treatment  of  perineal  lacerations. — Anaesthetics  in  midwifery. 

It  is  hardly  an  exaggeration  to  state  that  the  greater  proportion  of 
the  sins  of  midwifery  practice  are  committed  in  the  management  of 
normal  labors.  It  is  equally  easy  to  fall  into  errors  of  commission  and 
errors  of  omission.  It  is  as  necessary  to  know  when  to  abstain  as 
when  to  interfere.  It  is  an  old  but  always  good  rule,  not  to  meddle 
with  the  physiological  performance  of  a  function  ;  but  the  rule,  when 
applied  to  obstetrics,  presupposes  a  thorough  familiarity  with  the 
physiological  processes  of  childbirth,  and  the  contingencies  to  which 
women  in  parturition  are  exposed.  There  is  no  sense  in  reposing  a 
blind,  unreasoning  confidence  in  the  powers  of  Nature.    Indeed,  legit- 


CONDUCT  OF  NORMAL  LABOR. 


203 


imate  grounds  for  interference  are  liable  to  arise  in  the  simplest 
labors.  The  attitude  of  the  medical  attendant  should  be  one  of  watch- 
ful expectancy.  He  should  be  ready,  if  needful,  to  assuage  pain,  to 
forestall  dangers,  and  to  limit  the  duration  of  suffering. 

Preliminary  Preparations. — When  summoned  to  a  patient,  the  phy- 
sician should  go  armed  to  meet  the  sudden  emergencies  of  obstetrical 
practice.  His  armamentarium  should  include  a  silver  catheter,  an 
English  catheter  of  small  size  for  use  in  asphyxia  of  the  new-born 
child,  a  pair  of  forceps,  needles  and  needle-holder,  and  silk  or  wire  for 
sutures,  a  Davidson  syringe,  with  long  nozzle  for  uterine  injections, 
and  an  hypodermic  syringe.  He  should  go  provided  with  chloroform, 
Magendie's  solution  of  morphia,  ergot,  the  perchloride  or  persulphate 
of  iron,  and  a  small  vial  of  sulphuric  ether.  At  the  house,  ice,  brandy, 
and  hot  and  cold  water,  should  be  had  in  readiness. 

As  it  is  not  uncommon  for  women,  especially  among  the  poorer 
classes,  to  test  the  experience  of  young  physicians  by  asking  details 
relative  to  the  arrangement  of  the  bed  upon  which  the  confinement  is 
to  take  place,  it  is  trusted  that  a  few  words  upoTi  the  subject  will  not 
be  regarded  as  entirely  superfluous. 

The  bedstead  should  not  be  too  low.  If  against  the  wall,  it  should 
be  moved  out,  so  as  to  allow  easy  access  from  both  sides.  The  bedding 
should  consist  of  a  hair  mattress  or  of  a  straw  palliasse.  Feather-beds 
are  an  abomination.  Over  that  portion  of  the  mattress  upon  which 
the  woman  expects  to  lie,  a  rubber  cloth,  or  other  impervious  material, 
should  be  spread.  Next  to  the  water-proof,  nurses  usually  lay  a  folded 
woolen  comforter  or  blanket  to  absorb  the  fluid  discharges.  The  whole 
is  then  covered  smoothly  with  a  sheet,  and  a  second  sheet,  folded  in 
several  thicknesses,  is  laid  beneath  the  hips  of  the  patient.  All  these 
preparations  are  designed  to  limit  the  soiling  of  the  bedding  to  a  cir- 
cumscribed space,  and  to  facilitate  the  removal  of  the  discharges  after 
the  termination  of  the  delivery. 

Examination  of  the  Patient. — The  first  duty  which  devolves  upon 
the  physician  in  the  lying-in  chamber  is  to  examine  his  jaatient,  and  to 
inform  the  family  if  ^^all  is  right  " — i.  e.,  whether  the  head  presents, 
and  no  unusual  obstacle  to  delivery  exists.  It  is  a  good  plan  to  em- 
ploy external  palpation  in  every  case  where  no  opposition  is  made,  as, 
even  where  the  diagnosis  by  ordinary  vaginal  exploration  is  clear  and 
indisputable,  no  opportunity  should  be  lost  to  perfect  one's  self  in 
mapping  out  the  foetus  through  the  abdominal  and  uterine  walls. 
The  ability  not  only  to  recognize  the  presenting  part,  but  the  position 
of  the  entire  foetus  in  the  uterine  cavity,  is,  in  many  cases  of  difficult 
labor,  a  possession  of  priceless  value.  During  the  manipulation  of  the 
abdomen,  fetal  movements  should  be  carefully  noted.  If  absent,  aus- 
cultation should  be  practiced  to  ascertain  whether  the  child  is  still 
alive.    The  internal  examination  should  take  cognizance  of  the  condi- 


204 


LABOR. 


tion  of  the  vnlva  and  peringeum,  the  state  of  the  rectum  and  bladder, 
the  length  of  the  vagina,  the  degree  of  dilatation  and  softening  of  the 
cervix,  the  amount  of  cervical  and  vaginal  secretion,  the  hardness  of 
the  child's  head,  and,  if  the  membranes  are  not  ruptured,  the  quantity 
of  amniotic  fluid.  It  is  customary  to  begin  the  examination  during  an 
interval  between  the  pains,  but  it  is  often  convenient  to  continue  the 
investigation  during  the  pains,  in  order  to  judge  of  their  efficacy  and 
character. 

The  history  of  the  case  should  embrace  the  length  of  previous 
labors,  the  health  during  pregnancy,  the  number  of  times  the  woman 
has  been  pregnant,  and  whether  in  the  present  instance  she  has  ad- 
vanced to  full  time.  Inquiries  should  be  made  as  to  where  the  labor- 
pains  commenced,  as  to  their  frequency  and  situation,  and  if  the 
membranes  have  ruptured. 

After  the  examination  of  the  patient  is  ended,  the  physician  is  ex- 
pected to  express  an  opinion  as  to  the  probable  duration  of  the  labor. 
It  is,  however,  necessary  for  the  responses  upon  this  point  to  be 
guarded  and  Delphic.  In  general  terms,  when  the  pelvis  is  normal, 
the  head  well  flexed,  the  vagina  short,  and  the  cervix  and  perinaeum 
are  dilatable,  an  easy  and  rapid  labor  is  to  be  anticipated  ;  while,  per 
contra,  with  a  small  pelvis,  tardy  flexion,  a  long  vagina,  and  rigidity 
of  the  uterine  and  perineal  orifices,  a  tedious  period  of  waiting  is  to  be 
assumed.  Of  course,  too,  labor  is,  as  a  rule,  much  longer  in  primi- 
paras  than  in  women  who  have  previously  borne  children.  Moreover, 
with  few  exceptions,  the  result  depends  in  a  special  degree  upon  the 
energy  and  persistence  of  the  pains.  The  latter,  however,  represent 
always  the  uncertain  element  in  the  calculation.  If  the  pains  are 
good,  therefore,  the  reservation  should  be  made  that,  for  a  short  labor, 
they  must  continue  as  at  the  beginning  ;  while,  if  weak  and  powerless, 
it  should  be  stated  that  better  pains  will  be  needed  to  bring  the  labor 
to  a  speedy  conclusion. 

Management  of  the  First  Stage  of  Labor. 

The  duties  of  the  physician  during  the  first  stage  of  labor  are,  in 
normal  cases,  extremely  simple.  He  should  from  time  to  time,  say  at 
hourly  intervals,  repeat  the  examination,  with  a  view  to  inform  him- 
self of  the  progress  of  dilatation.  He  should  caution  his  patient  to 
pass  her  urine  frequently.  In  case  of  retention,  he  should  draw  the 
water  with  a  catheter.  When  the  head  is  low  down,  the  urethra  often 
follows  its  convexity.  The  introduction  of  the  straight  female  cathe- 
ter may  then  be  extremely  difficult.  Many  recommend  in  such  cases 
a  silver  male  catheter  to  which  a  suitable  curve  has  been  given.  I  use 
by  preference  the  English  flexible  catheter,  which  is  passed  easily,  pro- 
vided the  end  is  guided  by  the  index-finger,  through  the  anterior  vagi- 
nal wall,  to  the  point  of  contact  between  the  head  and  the  symphysis 


CONDUCT  OF  NORMAL  LABOR. 


205 


pubis.  A  flattening  of  the  tube  by  pressure  to  an  extent  causing 
obliteration  is  not  likely  to  take  place  unless  the  catheter  be  small  or 
has  become  over-pliable  from  long  use. 

If,  at  the  time  of  examination,  the  rectum  is  found  clogged  with 
faeces,  an  enema  should  be  ordered.  A  disposition  on  the  part  of  the 
patient#to  bear  down  during  the  first  stage  of  labor  should  be  dis- 
courage'd,  as  wasting  her  strength  without  possessing  any  counter- 
balancing utility.  The  patient  should  be  encouraged  not  to  take  to 
bed  at  the  outset  of  labor.  In  the  upright  or  sitting  posture,  gravity 
aids  the  fixation  of  the  head  and  promotes  dilatation. 

As  the  end  of  the  first  stage  approaches,  however,  the  woman 
should  undress  and  lie  down,  as  the  pains,  after  rupture,  as  a  rule, 
follow  one  another  with  rapidity,  and  make  locomotion  difficult.  To 
avoid  soiling,  the  night-dress  should  be  drawn  well  up  under  the  arms. 
Tidy  nurses  pin  a  folded  sheet  around  the  hips  of  their  patients  to 
arrest  the  soaking  of  fluids  upward. 

Eupture  of  the  membranes  is,  as  a  rule,  a  spontaneous  act.  Yet 
often  enough  something  may  be  done  in  the  way  of  shortening  labor, 
by  puncturing  the  membranes  so  soon  as  cervical  dilatation  is  com- 
plete. They  have  then  fulfilled  their  physiological  mission,  and  their 
persistence  simply  retards  the  advance  of  the  child's  head.  Artificial 
rupture  is  easily  effected  by  means  of  a  straightened  hairpin,  passed 
in  the  groove  between  the  index  and  middle  fingers  of  the  examining 
hand  to  the  amniotic  pouch.  The  puncture  should  be  made  during  a 
pain,  at  a  time  when  the  membranes  are  tense  and  separated  from  the 
scalp  by  a  deep  layer  of  fluid. 

Management  of  the  Second  Stage  of  Laboe. 

The  management  of  the  second  stage  of  labor  calls  for  considerable 
tact  on  the  part  of  the  medical  attendant.  It  is  incumbent  upon  him 
to  make  frequent  examinations,  to  determine  the  degree  of  rapidity 
with  which  the  descent  of  the  head  takes  place.  So  long  as  the  ad- 
vance is  regular,  he  should  abstain  from  interference.  Should  the 
pains  slacken,  however,  he  should  not  allow  the  duration  of  the  second 
stage  to  exceed  the  physiological  limits.  It  is  not  easy  to  define  ex- 
actly what  is  implied  in  the  expression  ^'physiological  limits."  As  a 
rule,  a  very  rapid  second  stage  is  not  physiological,  as  it  endangers  the 
integrity  of  the  vagina  and  perinaeum,  and  predisposes  to  post-partum 
haemorrhage.  Still,  now  and  then  labor  is  ended  by  a  single  pain  after 
rupture  of  the  membranes,  without  detriment  to  the  mother.  Of 
course,  such  cases  are  extremely  uncommon  in  primiparse.  They  re- 
quire an  unusually  distensible  condition  of  the  soft  parts,  and  an  ex- 
traordinary degree  of  resiliency  in  the  uterus.  On  the  other  hand, 
pressure  of  the  head,  after  its  descent  into  the  pelvic  cavity,  leads,  if 
too  long  continued,  to  pathological  changes  in  the  tissues  of  the  canal 


206 


LABOR. 


and  of  the  outlet.  It  is  usual,  therefore,  unless  the  head  is  small  or 
the  pelvis  roomy,  to  use  the  resources  of  art  to  terminate  labor  when 
the  head  remains  stationary  at  the  perineal  floor  after  two  hours  of 
effort.  It  is  desirable,  therefore,  when  the  pains  are  weak  and  ineffec- 
tive, to  utilize  all  the  simple  adjuvants  which  experience  has  shown  to 
possess  real  efficacy  in  increasing  the  activity  of  labor.  * 

Changes  of  posture  increase  the  power  of  the  pains  temporarily. 
When  head-flexion  is  incomplete,  it  has  been  recommended  to  place 
the  patient  upon  the  side  toward  which  the  occiput  is  turned.  Others, 
again,  claim  that  the  descent  Vf  the  occiput  is  best  effected  by  plac- 
ing the  mother  upon  the  side  toward  which  the  chid's  forehead  is 
directed.  In  point  of  fact,  either  posture  frequently  leads  to  the 
desired  result,  simply  because  the  change  from  the  dorsal  to  the 
lateral  position  is  apt  to  be  followed  by  a  temporary  addition  to  the 
uterine  force.* 

In  many  women,  owing  to  defective  innervation,  or  to  insufficient 
development  of  the  muscular  structures  of  the  uterus,  it  is  of  great 
moment  that  the  expulsion  of  the  child  be  aided  by  the  voluntary 
pressure  of  the  abdominal  walls.  To  be  sure,  in  most  cases,  the  reflex 
impulse  to  bear  down  is  imperative  ;  but  in  others,  where  the  impulse 
is  feeble  or  held  in  abeyance  by  the  dread  of  th^  patient  lest  she  in- 
crease her  sufferings,  it  becomes  the  duty  of  the  physician,  in  tardy 
labors,  to  see  to  it  that  all  the  auxiliary  forces  are  brought  into  play. 
To  this  end  he  should  instruct  his  patient  to  fix  her  pelvis,  either  by 
pressing  her  feet  against  the  foot-board  of  the  bed,  or  by  drawing  up 
her  knees  and  resting  them  against  an  assistant,  who  assumes  the  posi- 
tion best  adapted  to  furnish  the  requisite  support.  Then  the  nurse, 
or  other  suitable  person,  should  grasp  the  woman's  hands,  so  as  to 
enable  her  to  fix  her  thorax  and  to  bring  all  the  expiratory  muscles 
into  full  exercise.  Often,  when  the  agony  is  intense,  the  patient 
can  be  induced  to  strain  with  her  pains,  if  her  sufferings  are  first 
dulled  by  small  doses  of  chloroform.  When  the  head  is  on  the  peri- 
nceum,  the  physician  may  further  expulsion  by  rubbing  the  abdomen 
to  excite  pains,  and  by  pressing  upon  the  breech  through  the  fun- 
dus. 

During  the  second  stage  the  patient's  posture  should  be  left  in 
general  to  her  own  volition.  The  physician  should  accustom  himself 
to  conduct  labor  with  equal  facility,  no  matter  whether  the  woman 
lies  upon  her  side  or  upon  her  back.  The  left  lateral  position,  affected 
by  English  accoucheurs,  is  very  convenient  at  the  time  of  delivery, 
especially  when  there  is  occasion  to  support  the  perinaeum,  and  where, 
owing  to  the  flatness  of  the  nates,  the  vulva  is  scarcely  raised  in  the 
dorsal  posture  above  the  level  of  the  bedding. 


*  Lahs,  "Die  Thcorie  der  Geburts.,"  Bonn,  1877,  p.  237. 


CONDUCT  OF  NORMAL  LABOR. 


207 


The  Preservation"  of  the  Perii^jeum. 

By  far  the  most  delicate  task  which  the  physician  has  to  fulfill 
toward  his  i^atient  in  the  expulsion  stage  consists  in  so  regulating  the 
exit  of  the  child's  head  as  best  to  avoid  perineal  lacerations.  It  is 
needless  to  state  that  such  lacerations,  unless  of  slight  extent,  entail 
upon  women  a  variable  degree  of  subsequent  discomfort  and  suffering. 
When  the  perin^eum  is  examined  with  care  after  labor,  a  practice  which 
should  be  invariable  with  a  conscientious  attendant,  the  frequent  oc- 
currence of  more  or  less  extensive  rupture  of  its  tissues  is  a  matter  of 
easy  confirmation.  Statistics  of  their  frequency  are  of  little  value, 
much  depending  upon  individual  skill  in  management.  Olshausen  * 
reports,  as  the  result  of  the  preventive  measures  adopted  at  the  clinic 
in  Halle,  during  a  period  of  ten  years,  21 '1  per  cent,  of  perineal  in- 
juries in  primiparae  and  4*7  per  cent,  in  multiparae.  These  percent- 
ages did  not  include  slight  tears  confined  to  the  fraenulum.  He  regards 
15  per  cent,  as  not  too  high  an  estimate  for  the  absolutely  unavoidable 
lacerations,  due  to  defective  distensibility  of  the  perinseum,  and  to  the 
disproportionate  size  of  the  child's  head. 

The  aim  of  prophylactic  measures  should  be  to  develop  the  elas- 
ticity of  the  soft  parts  to  the  fullest  practicable  extent,  and  to  cause  the 
head  to  pass  through  the  distended  orifice  of  the  vulva  by  its  smallest 
diameter.  Preliminary  softening  of  the  perinaeum  is  best  accomplished 
by  the  continuous  but  not  too  rapid  descent  of  the  presenting  part. 
The  relaxation,  as  a  rule,  begins  earlier  and  is  more  complete  in  mul- 
tiparae  than  in  primiparas.  In  a  few  cases  the  soft  parts  will  already 
have  ceased,  by  the  end  of  the  first  stage  of  labor,  to  offer  any  effec- 
tive barrier  to  delivery.  The  distensibility  of  the  soft  parts  may  be 
fairly  inferred  from  the  presence  of  a  copious  discharge  of  glairy  mucus. 

When  rupture  takes  place,  the  vaginal  mucous  membrane  is  the 
first  structure  to  give  way.  In  the  ordinary  form,  the  perineal  body 
tears  from  the  commissure  backward  to  the  rectum.  In  rare  cases,  a 
central  perforation  may  result,  and  the  child  be  expelled  through  a 
rent  situated  between  the  vulva  and  the  anus. 

AVhen  the  head  begins  to  make  the  perinaeum  bulge,  the  physician 
should  be  on  the  alert,  and  inform  himself  during  each  contraction  6f 
the  strain  to  which  the  parts  are  subjected.  At  first  it  is  only  neces- 
sary to  rest  the  hand  lightly  upon  the  perinaeum.  Direct  pressure  is 
to  be  avoided,  except  when  the  peringeum  is  stretched  to  a  membranous 
thinness,  and  the  danger  of  central  perforation  threatens.  As  the  head 
begins  to  distend  the  vulva,  the  tension  at  the  fraenulum  should  be 
carefully  gauged  by  a  finger  introduced  between  the  labia.  Measures 
to  avert  rupture  may  be  classified  under  three  headings,  viz. : 

*  Olshausen,  "  Ucbcr  Dammverlctzung  und  Dammschutz,"  Volkraann's  '*  Samml.  klin. 
Vortr.,"  No.  41,  p.  360. 


208 


LABOR. 


1.  Those  designed  to  check  the  exit  of  the  head  before  the  fullest 
expansion  has  been  secured,  and  to  prevent  expulsion  during  the  acme 
of  a  pain,  when  the  borders  of  the  orifice  are  most  rigid. 

2.  Measures  which  impart  an  upward  movement  to  the  head,  with 
a  view  of  making  all  unoccupied  space  beneath  the  arch  of  the  pubes 
available. 

3.  Measures  which  favor  expulsion  during  the  interval  between  the 
pains,  or  at  least  after  the  acme  has  subsided. 

In  ordinary  cases  HoliFs  method,  recommended  by  Olshausen,*  has 
rendered  me  excellent  service. %  It  consists  in  applying  the  support, 
not  to  the  perinaeum,  but  to  the  presenting  part.  To  this  end  the 
thumb  should  be  applied  anteriorly  to  the  occiput,  and  the  index  and 
middle  fingers  posteriorly  upon  that  portion  of  the  head  which  lies 
nearest  to  the  commissure.  The  unconstrained  position  of  the  hand 
enables  the  operator  to  exercise  effective  pressure  in  the  direction  of 
the  vagina,  while  the  posterior  fingers  favor  the  rotation  of  the  head 
under  the  pubic  arch.  The  patient  should  at  the  same  time  be  directed 
not  to  hold  her  breath  during  the  pains,  except  when  they  are  weak 
and  powerless.  Where  tlie  impulse  to  bear  down  is  irresistible,  chlo- 
roform should  be  given  to  annul  the  excessive  reflex  irritability. 
Under  the  most  skillful  management,  laceration  is  liable  to  occur, 
unless  the  physician  is  able  to  control  the  action  of  the  auxiliary  ex- 
pulsive forces. 

So  soon  as  the  bi-parietal  diameter  passes  the  tense  border  of  the 
vulva,  the  perinaeum  retrj^ts  rapidly  over  the  face,  and  the  expulsion 
of  the  head  is  completed.  It  is  during  this  period  that  laceration  is 
most  apt  to  occur.  This  danger  is,  however,  greatly  lessened  if  the 
head  is  made  to  issue  through  the  orifice  after  the  pain  has  subsided, 
and  when  the  soft  parts  are  in  a  relaxed  and  dilatable  condition.  To 
accomplish  this,  in  many  instances  where  the  resistance  to  be  over- 
come is  slight,  it  is  sufficient  for  the  woman  to  hold  her  breath  during 
an  interval  between  the  pains,  and  voluntarily  call  into  play  all  the 
muscles  of  expiration.  In  the  larger  proportion  of  cases,  however, 
these  efforts  are  futile,  because  of  the  comparatively  feeble  motor-force 
brought  into  action. 

i^An  excellent  method  of  manual  delivery  we  owe  to  Ritgen,f  which 
consists  in  lifting  the  head  upward  and  forward  through  the  vulva, 
between  the  pains,  by  pressure  made  with  the  tips  of  the  fingers 
upon  the  peringeum  behind  the  anus,  close  to  the  extremity  of  the 
coccyx.  Of  course,  the  method  is  only  available  after  the  head  has 
descended  sufficiently  for  the  pressure  to  be  cxorted  upon  the  frontal 
region. 

*  Olshausen,  he.  cit.,  p,  866. 

f  Olshausen,  "  Uebcr  Daramverletzung  imd  Damraschutz,"  Volkmaim's  "  Samralung.," 
No.  41,  p.  369. 


CONDUCT  OF  NORMAL  LABOR. 


209 


Rectal  expression  has  lately  found  warm  advocates  in  Olshausen* 
and  Ahlfeld.f  The  manoeuvre  consists  in  passing  two  fingers  into  the 
rectum  toward  the  close  of  the  second  stage  of  labor,  and  hooking 
them  into  the  mouth  or  under  the  chin  of  the  child  through  the  thin 
recto-vaginal  septum.  By  pressing  the  face  forward  and  upward,  the 
normal  rotation  of  the  head  beneath  the  pubic  arch  can  be  effected, 
and  delivery  can  be  accomplished  between  the  pains  at  the  will  of  the 
operator. 

When  rupture  is  felt  to  be  imminent,  mock-modesty  should  be  dis- 
carded, and  the  parts  imperiled  should  be  unhesitatingly  exposed  to 
view.  If,  owing  to  its  excessive  elasticity,  the  occiput,  in  place  of 
being  directed  forward  to  the  vulva  by  the  perinseum,  distends  the 
latter  so  that  central  perforation  threatens/ the  hand  should  be  applied 
in  such  a  way  as  to  give  direct  support  to  the  stretched  tissues  and  to 
guide  the  head  upward  to  the  outlet.  If,  on  the  other  hand,  the 
danger  arises  from  defective  elasticity,  the  physician,  standing  to  the 
right  of  the  patient,  with  his  face  toward  the  foot  of  the  bed,  should 
pass  the  left  hand  between  her  thighs  and  press  the  head  upward  and 
inward,  during  each  joain,  with  the  thumb  and  two  fingers,  as  previ- 
ously described.  At  the  same  time,  the  movement  of  extension,  should 
it  threaten  danger  to  the  parts,  should  be  hindered  by  pressing  back- 
ward upon  the  frontal  region,  through  the  perinaeum,  with  the  disen- 
gaged hand. 

|f  Dr.  Goodell  I  recommends  hooking  two  fingers  into  the  anus,  and 
drawing  the  perinseum  forward  during  a  pain,  to  remove  the  strain 
from  the  thinned  border  of  the  vulva,  and  to  promote  the  elasticity  of 
the  tissues. 

^Fasbender  *  places  the  patient  upon  the  left  side  ;  then,  standing 
behind  her,  he  seizes  the  head  between  the  index  and  middle  fingers  of 
the  right  hand,  applied  to  the  occiput,  and  the  thumb  thrust  as  far 
into  the  rectum  as  possible.  By  this  manoeuvre  the  head  is  held  under 
complete  control,  the  rectal  wall  hardly  affecting  the  grip  in  any  ap- 
preciable manner.  Duriug  a  pain  the  progression  and  extension  of 
the  head  are  readily  prevented.  During  the  interval  between  the 
pains,  by  pressure  with  the  thumb  through  the  rectum  and  the  poste- 
rior portion  of  the  perinaeum,  the  head  can  be  pressed  forward  and  out- 
v(^d  at  the  will  of  the  operator. 

^^etween  pains,  I  have  been  in  the  habit,  in  cases  of  rigidity,  of 
alternately  drawing  the  chin  downward  through  the  rectum  until  the 
head  distends  the  perinaeum,  and  then  allowing  it  to  recede.    It  is  as- 

*  See  Ahlfeld,  "  Das  Dammsehutz  Verfahren  nach  Ritgen,"  "  Arch.  f.  Gynack.,"  vi, 
p.  279. 

f  Loc.  cit. 

X  Goodell,  "Am.  Jour,  of  the  Med.  Sci.,"  January,  1871. 

*  Fasbender,  "  Ztschr.  f.  Geburtsh.  und  Gynaek.,"  Bd.  ii,  H.  1,  p.  58. 

U 


210 


LABOR. 


tonisliing  liow  often  aj^parently  the  most  obstinate  resistance  can  be 
overcome  by  the  simple  repetition  of  this  to-and-fro  movement,  the 
parts  rapidly  becoming  soft  and  distensible.  Of  course,  it  should  be 
discontinued  the  moment  contraction  begins,  and  care  should  be  taken 
to  effect  delivery  after  uterine  action  has  subsided. 

With  judicious  management  the  number  of  unavoidable  lacerations 
can  be  restricted  to  a  small  proportion  of  cases.  Still  there  are  indi- 
vidual peculiarities  which  will  now  and  then  render  abortive  the  best 
prophylactic  measures.  In  this  category  I  have  already  alluded  to  a 
primitive  lack  of  development  of  the  maternal  parts,  to  unusual  size 
of  the  child's  head,  and  to  the  excessive  rigidity  of  the  peringeum  in 
primiparae,  especially  after  the  thirtieth  year.  In  addition,  should  be 
mentioned  cases  where  the  pubic  arch  is  diminished  by  the  approxi- 
mation of  the  pubic  rami,  or  Avhere  the  tissues  have  been  rendered 
friable  from  chronic  oedema,  from  a  varicose  condition  of  the  veins, 
from  condylomata,  from  syphilitic  sores,  or  from  inflammatory  infil- 
tration consequent  upon  undue  prolongation  of  the  second  stage  of 
labor.  Lacerations  are  more  frequent  in  occipito-posterior  positions, 
and  in  the  delivery  of  the  after-coming  head,  where  hasty  extraction 
is  demanded  in  the  interest  of  the  child. 

When,  in  the  judgment  of  the  physician,  rupture  of  the  perinaeum 
seems  inevitable,  he  is  justified  in  making  lateral  incisions  through  the 
vulva  to  relieve  the  strain  upon  the  recto-vaginal  septum.  To  this 
operation  the  term  episiotomy  is  applied.  By  it  not  only  is  the  danger 
of  deep  laceration  through  the  sphincter  ani  prevented,  but,  owing  to 
their  eligible  position,  the  wounds  themselves  are  capable  of  closing  spon- 
taneously ;  whereas,  when  laceration  follows  the  raphe,  the  retraction  of 
the  transversi  perinasi  muscles  causes  a  gaping  to  take  place  which  inter- 
feres with  immediate  union.  As,  however,  every  wounded  surface  is  a 
source  of  danger  in  childbed,  episiotomy  should  never  be  performed 
so  long  as  hope  exists  of  otherwise  preserving  the  perinaBum.  It  is 
essentially  the  operation  of  young  practitioners,  the  occasions  for  its 
employment  diminishing  in  frequency  with  increasing  experience. 
The  chief  resistance  encountered  by  the  head  is  not  at  the  thin  border 
of  the  vulva,  but  is  furnished  by  a  narrow  ring  situated  half  an  inch 
above,  and  composed  of  the  constrictor  cunni,  the  transversi  perinaei, 
and  sometimes  of  the  levator  ani  muscles.  Incisions  should  be  made 
during  a  pain,  when  the  ring  becomes  tense  and  rigid,  and  is  ea^y 
recognized  with  the  finger.  As  it  is  not  desirable  that  the  head  should 
be  driven  suddenly  through  the  vulva  during  the  act  of  operating,  the 
time  selected  for  performing  episiotomy  should  be  at  the  commence- 
ment or  close  of  a  contraction.  The  division  of  the  rigid  fibers  may 
be  accomplished  by  means  of  a  blunt-pointed  bistoury,  or  a  pair  of 
angular  scissors.  So  far  as  practicable,  the  incisions  should  be  con- 
fined to  the  vagina,  and  should  not  exceed  three  quarters  of  an  inch 


CONDUCT  OF  NORMAL  LABOR. 


211 


in  length.  In  cases  where  the  head  is  on  the  eve  of  expulsion,  the 
bistoury  may  he  introduced  flat  between  it  and  the  vagina,  half  an  inch 
anterior  to  the  commissure,  and  the  section  made  from  within  outward. 
Care,  however,  should  be  taken  at  the  same  time  to  avoid  severing  the 
external  skin,  by  drawing  it  as  far  back  as  possible.  *  In  central  per- 
foration it  is  best  to  divide  the  band  left  attached  to  the  vulva,  as  its 
preservation  is  of  no  advantage. 

The  Delivery  of  the  Shoulders. — After  the  expulsion  of  the  head, 
mucus  should  be  wiped  from  the  mouth  and.  nose,  and  cleared  from 
the  throat  with  the  finger,  should  laryngeal  rales  indicate  an  embar- 
rassment of  the  respiration.  If  the  cord  is  found  coiled  around  the 
neck,  it  should  be  loosened  by  drawing  upon  the  placental  end  until 
the  shoulders  can  pass  readily  through  the  loop .  Should  this  be  found 
impossible,  either  because  the  cord  is  unusually  short,  or  because  it  is 
wound  several  times  around  the  body,  a  ligature  should  be  applied, 
the  cord  should  be  cut  between  the  ligature  and  the  placenta,  and  de- 
livery should  be  hastened  by  manual  efforts,  f 

In  the  majority  of  cases  the  shoulders  are  expelled  spontaneously. 
Still,  it  is  a  good  plan  to  expedite  the  descent  by  pressure  made  with 
the  left  hand  at  the  fundus  of  the  uterus.  Care  must  be  taken  lest 
the  lower  shoulder  convert  a  slight  tear  in  the  perinseum  into  an  ex- 
tensive laceration.  The  right  hand  should  therefore  be  applied  to  the 
perinaeum  in  such  a  way  as  to  lift  the  shoulder  upward,  and  at  the  same 
time  furnish  a  bridge  over  which  it  can  glide  in  its  movement  forward. 
Sometimes  after  the  passage  of  the  head  a  deep  vaginal  laceration  co- 
exists with  an  intact  condition  of  the  external  parts.  The  shoulder 
then  tears  through  the  skin,  and  a  complete  rupture  ensues.  Olshau- 
sen  recommends,  in  cases  where  rupture  is  imminent,  to  turn  the  shoul- 
ders so  that  they  clear  the  vulva  in  an  oblique  or  transverse  diameter. 

If,  after  birth  of  the  head,  the  child  does  not  breathe,  and  asphyxia 
threatens,  the  physician  should  rub  the  uterus  with  the  hand  through 
the  abdominal  wall,  to  excite  a  pain,  during  which  he  should  urge  the 
patient  to  press  down,  and  thus  aid  expulsion.  The  most  common 
hindrance  to  delivery  consists  in  an  arrest  of  the  upper  shoulder  be- 
neath the  pubes.  Usually  its  release  is  readily  effected  by  seizing  the 
sides  of  the  head  with  the  two  hands  and  drawing  directly  downward. 
It  is  rarely  necessary  to  raise  the  head  subsequently,  or  to  hook  the 
finger  into  the  armpit  to  extract  the  posterior  shoulder. 

Tying  the  Cord. — When  the  cord  is  torn  across,  as  sometimes  hap- 
pens in  street-births,  no  haemorrhage  takes  place  from  the  lacerated 
vessels.    Of  course,  this  occurrence  deprives  the  physician  of  the 

*  Olshausen,  he.  cit.,  pp.  372,  873. 

f  Tarnier  recommends  dividing  the  cord,  and  then  compressing  the  proximal  end  be- 
tween the  thumb  and  the  index-finger.  The  proximal  end  is  distinguished  by  the  spout- 
ing of  the  two  umbilical  arteries. 


212 


LABOR. 


power  of  choosing  the  point  at  which  the  division  shall  be  made.  As 
it  is  desirable,  for  the  sake  of  convenience,  to  sever  the  cord  about  two 
inches  from  the  navel,  it  is  the  custom  in  all  civilized  countries  to  cut 
it  with  scissors,  and  to  prevent  haemorrhage  by  the  application  of  a 
ligature.  Almost  any  material  may  be  employed  for  the  latter  purpose, 
though  nothing  is  so  handy  as  the  narrow  flat  bobbin  which  most 
nurses  keep  in  readiness.  The  ligature  should  be  applied  tightly,  and 
the  cut  surface  should  subsequently  be  examined  once  or  twice  by  the 
physician  before  leaving,  to  make  sure  that  the  arteries  are  suffi- 
ciently compressed  to  prevent  oozing  from  taking  place.  The  cord 
should  be  held  in  the  hollow  of  the  hand  at  the  time  of  its  division, 
to  avoid  the  possibility  of  including  accidentally  any  portion  of  the 
child  between  the  blades  of  the  scissors.  Commonly  two  ligatures 
are  applied,  and  the  cord  is  severed  between  them,  though  the  ques- 
tion of  one  or  two  ligatures  is,  except  in  twin  pregnancies,  of  trifling 
importance. 

In  practice  it  is  very  desirable  that  the  physician  should  understand 
the  physiological  difference  between  the  effects  of  the  early  and  those 
of  the  late  application  of  the  ligature.  The  custom,  as  regards  this 
point,  has  been  by  no  means  uniform.  The  ancients  deferred  the  liga- 
ture until  after  the  expulsion  of  the  placenta.  Mauriceau,  Clement, 
and  Deventer  followed  the  same  plan,  but  employed  artificial  expe- 
dients to  complete  the  third  stage  of  labor  rapidly.*  The  common 
practice  at  the  present  day  is  to  tie  the  cord  immediately  after  the 
birth  of  the  child.  Still,  there  have  not  been  wanting  in  recent 
times  warning  voices  against  precipitate  action.  Nagel  advised  wait- 
ing until  the  pulsation  of  the  cord  had  ceased  ;  Braun  f  first  describes 
the  changes  from  the  fetal  to  the  post-natal  circulation,  and  then  says  : 
This  stupendous  process  should  be  taken  into  consideration  in  the 
treatment  of  every  case  of  labor,  and  because  of  it  the  cord  should 
never  be  severed  or  tied  so  long  as  pronounced  pulsations  can  be  felt 
near  the  navel."  Stoltz  J;  noticed  that,  "  after  the  child  has  respired 
well,  division  of  the  cord  is  followed  by  an  insignificant  loss  of  blood, 
while,  after  immediate  section,  blood  escapes  in  abundance." 

In  1875  Budin,  at  that  time  interne  at  the  Maternite  of  Paris, 
undertook  the  following  experiments  at  the  suggestion  of  Professor 
Tarnier  :  In  one  series,  the  cord  was  tied  immediately  after  the  birth 
of  the  child,  and  the  blood  which  escaped  from  the  placental  extrem- 
ity was  measured  ;  in  the  other,  the  quantity  of  blood  was  determined 
in  cases  where  the  cord  was  not  tied  until  several  minutes  after  de- 
livery.   By  a  comparison  of  the  results  thus  obtained,  he  found  that 

*  Budin,  "  A  quel  moment  doit-on  operer  la  ligature  du  cordon  ombilical  ?  "  "  Publi- 
cations du  '  Progr^s  Medical',''  1876. 

f  Braun,  "Lehrbuch  der  Geburtshulfe,"  p.  192. 

:j:  Stoltz,  art.  "  Accouchement  naturel,"  *'  Nouvcau  Dictionnaire,"  p.  283. 


CONDUCT  OF  NORMAL  LABOR. 


213 


the  average  amount  of  placental  blood  was  three  ounces  greater  in 
the  first  than  in  the  second  series  of  experiments.*  Welcker  estimated 
the  entire  quantity  of  the  blood  in  the  infant  at  one  nineteenth  the 
weight  of  the  body,  which  would  amount,  in  a  child  of  seven  pounds, 
to  six  ounces.  To  tie  the  cord  immediately  after  birth  would  there- 
fore be  equivalent  to  robbing  the  child  of  three  ounces  of  blood  which 
would  otherwise  pass  into  its  circulation.  This  startling  result  has  in 
the  main  been  abundantly  confirmed  by  subsequent  observers.  Two 
years  later  (1877),  Schiicking,  extending  Budin's  experiments  by 
weighing  the  child  at  birth,  and  then  observing  the  changes  that  took 
place  up  to  the  time  of  the  cessation  of  the  placental  circulation,  found 
that  the  child  gained  from  one  to  three  ounces  in  weight  by  delay.  It 
is  certain  that  these  amounts  do  not  represent  the  entire  increase,  as  a 
portion  necessarily  escapes  observation  in  the  interval  that  must  elapse 
before  the  weight  can  be  ascertained. 

There  is  a  difference  of  opinion  as  to  the  mechanism  by  which  the 
transfer  of  the  blood  from  the  placenta  to  the  child  takes  place.  Ac- 
cording to  Budin,  the  princiioal  factor  in  the  accomplishment  of  the 
result  is  thoracic  aspiration.  With  the  first  breath,  the  afflux  of  blood 
to  the  lungs  develops  a  negative  pressure  "  in  the  vessels  of  the  larger 
circulation,  so  that  a  suction  force  is  exerted  upon  the  placental  blood, 
which  continues  until  the  equilibrium  is  restored.  To  tie  the  cord 
prematurely,  therefore,  is  to  cut  off  from  the  child  a  supply  of  blood 
for  which  the  establishment  of  the  pulmonary  circulation  had  created 
a  physiological  need. 

Schiicking,  t  on  the  contrary,  maintains  that,  after  the  first  inspira- 
tion, thoracic  expansion  ceases  to  operate  as  an  active  force,  and  that 
the  main  agent  which  drives  the  blood  from  the  placenta  through  the 
umbilical  vein  is  the  compression  exerted  by  the  retraction,  and,  at 
intervals,  by  the  contractions  of  the  uterus. 

The  difference  in  the  theoretical  standpoint  of  these  two  observers 
is  of  practical  importance,  for,  if  the  movement  of  blood  to  the  child 
results  from  thoracic  aspiration,  the  quantity  which  enters  its  circula- 
tion will  not  exceed  its  requirements  ;  while,  if  the  movement  is  due 
to  uterine  compression,  the  question  arises  as  to  whether  the  forcible 
transfusion  thus  accomplished  is  compatible  with  the  child's  safety 
and  welfare.  The  ultimate  decision  will  depend  partly  upon  experi- 
mental and  partly  upon  clinical  observations.  Provisionally,  the  case 
stands  as  follows  :  The  manometric  observations  of  Ribemont  J  show 
that  the  pressure  in  the  umbilical  arteries  is  uniformly  greater  than  that 

*  BuDiN,  he.  cit. 

f  ScHUCKiNG,  "  Zur  Physiologie  der  Nachgeburtsperiode,"  "Berl.  klin.  Woch.,"  Nos. 
1  and  2,  1877. 

X  RinEMONT,  *'  Recherches  sur  la  tension  du  sang  dans  les  vaisseaux  du  foetus  et  du 
nouvcau-nc,"  "Arch,  dc  Tocol.,"  October,  1879. 


214 


LABOR. 


in  the  umbilical  vein  ;  during  a  series  of  deep  inspirations  and  expi- 
rations, the  blood  in  the  umbilical  vein  is  subject  to  marked  oscilla- 
tions :  after  the  pulsations  of  the  cord  have  ceased,  the  uterine  con- 
tractions alone  are  insufficient  to  propel  the  placental  blood  through 
the  umbilical  vein  to  the  infant.  Again,  Budin  (discussion  upon 
Ribemont's  paper),  in  a  breech-delivery,  compressed  the  cord  at  the 
vulva  as  far  as  possible  from  the  navel ;  at  birth,  the  vein  was  dis- 
tended with  blood,  but  with  the  first  inspiration  it  was  instantly 
emptied.  Thoracic  aspiration  does,  therefore,  exist  as  an  operative 
force.  On  the  other  hand,  Schiicking  found  that  when  the  placenta 
was  rapidly  expelled  by  Crede's  method,  so  as  to  remove  it  from  the 
influence  of  uterine  retraction,  the  pressure  in  the  vein  was  slightly 
lessened,  and  the  total  amount  of  blood  transferred  to  the  infant  was 
greatly  restricted. 

According  to  the  clinical  observations  of  Budin,  Eibemont,  and 
Schiicking,  infants  which  have  had  the  benefit  of  late  ligation  of  the 
cord  are  red,  vigorous,  and  active,  whereas  those  in  which  the  cord 
is  tied  early  are  apt  to  be  pale  and  apathetic.  Hofmeier,*  Ribemont, 
Budin,  and  Zweifel  f  have  shown  that  the  loss  of  weight  which  occurs 
in  the  first  few  days  following  confinement  is  less  in  amount  and  of 
shorter  duration  when  the  cord  is  not  tied  until  after  the  pulsations 
have  ceased. 

There  appear  to  be  no  harmful  results  to  the  child,  growing  out  of 
the  practice  of  late  ligation.  Porak,  indeed,  reports  two  cases  of  dark 
vomiting,  two  of  melaena,  and  two  with  sanguineous  discharges  from 
the  vagina,  which  he  is  convinced  were  the  result  of  the  practice  ;  but 
the  extensive  trial  to  which  it  has  since  been  subjected  in  the  principal 
lying-in  institutions  of  the  Continent  have  sufficiently  demonstrated 
that  it  is  exempt  from  danger. 

In  late  ligation,  the  amount  of  blood  retained  in  the  placenta  and 
the  increase  in  the  weight  of  the  child  differ  materially  in  different 
cases,!  a  difference  which  seems  to  indicate  that,  so  long  as  the  placen- 
tal circulation  is  left  undisturbed,  the  amount  of  blood  passing  to  the 
child  will  be  measured  by  its  needs.  In  a  case  of  Illing's,*  on  the 
other  hand,  after  the  placenta  had  been  expressed  from  the  uterus,  its 
contents  and  that  of  the  cord  were  forcibly  squeezed  into  the  circula- 
tion of  the  child,  and  death  followed  from  over-distention  of  the  heart. 
Porak  and  Georg  Violet  ||  claim  that  there  is  a  special  predisposition 

*  "Der  Zeitpiinkt  dcr  Abnabclung,"  etc.,  "Ztschr.  f.  Geburtsli.  u.  Gynaek.,"  iv,  1,  p. 
114. 

f  Zweifel,  "  Centralbl.  f.  Gynaek.,"  No.  1. 

X  See  Wiener,  "  Ucbcr  die  Einfluss  der  Abnabclunf:^szcit  auf  den  Blutgehalt  dor 
Placenta,"  "Arch.  f.  Gynaek.,"  xiv,  1,  p.  34;  also,  Meyer,  "Centralbl.  f.  Gynaek,," 
1878,  No.  10.  #  "  Inaug.  Diss.,"  Kiel,  1877. 

II  Georg  Violet,  "  Ucbcr  die  Gelbsucht  dcr  Neugcborcnen  und  die  Zcit  dcr  Abaabc- 
lung,"  ViRCHOw's  "  Arcliiv,"  Ixxx,  2,  p.  353. 


CONDUCT  OF  NORMAL  LABOR. 


215 


to  icterus  in  children  when  the  cord  is  tied  after  the  placental  circula- 
tion has  ceased.  Violet  attributes  the  discoloration,  not  to  bile-pig- 
ment, but  to  a  rapid  disintegration  of  the  excess  of  blood-corpuscles. 
Helot,  he  says,  found,  on  the  first  day  after  the  birth,  a  difference  of 
nine  hundred  thousand  corpuscles  to  the  cubic  millimetre  between 
cases  of  late  and  those  of  early  ligation,  while  on  the  ninth  day  the 
difference  fell  to  three  hundred  thousand.  Others  have  failed  to 
notice  any  characteristic  icteric  discoloration  peculiar  to  late  ligation. 
JSTeither  Porak  nor  Violet  attaches  any  pathological  significance  to  the 
symptom. 

The  outcome  of  the  foregoing  observations  may  fairly  be  stated  as 
follows  : 

1.  The  cord  should  not  be  tied  until  the  child  has  breathed  vigor- 
ously a  few  times.  When  there  is  no  occasion  for  haste  arising  out  of 
the  condition  of  the  mother,  it  is  safer  to  wait  until  the  pulsations  of 
the  cord  have  ceased  altogether. 

2.  Late  ligation  is  not  dangerous  to  the  child.  From  the  excess  of 
blood  contained  in  the  fetal  portion  of  the  placenta,  the  child  receives 
into  its  system  only  the  amount  requisite  to  supply  the  needs  created 
by  the  oj^ening  up  of  the  pulmonary  circulation. 

3.  Until  further  observations  have  been  made,  the  practice  of  em- 
ploying uterine  expression  previous  to  tying  the  cord  is  questionable. 

4.  In  children  born  pale  and  anaemic,  suffering  at  birth  from  syn- 
cope, late  ligation  furnishes  an  invaluable  means  of  restoring  the  equi- 
librium of  the  fetal  circulation. 

Maxagemext  of  the  Thied  or  Placental  Stage  of  Labor. 

Tlie  duties  of  the  physician  in  the  third  stage  are  to  guard  against 
haemorrhage,  to  joromote  uterine  contractions,  and  to  further  the  ex- 
pulsion of  the  placenta.  These  objects  are  best  fulfilled  by  manipula- 
tions through  the  abdominal  walls.  Tractions  upon  the  cord  should 
not  be  resorted  to  before  the  i)lacenta  begins  its  descent  into  the 
vagina.  The  method,  at  present  in  vogue,  of  expressing  the  placenta 
by  seizing  the  uterus  through  the  abdominal  coverings,  is  associated 
indissolubly  with  the  name  of  Crede,  for,  though  the  value  of  friction, 
of  kneading,  and  compression,  was  appreciated,  as  their  writings  show, 
by  Mauriceau,  Robert  Wallace  Johnson,  Joseph  Clarke,  Busch,  Mayer, 
and  others,*  it  remained  for  Crede  to  elevate  placental  expression  to 
the  rank  of  a  recognized  procedure  of  obstetric  practice. 

Crede's  method  consists  essentially  in  applying  at  first  light  and 
afterward  stronger  friction  to  the  fundus  of  the  uterus  until  an  ener- 
getic contraction  is  obtained  ;  at  its  height  the  uterus  is  grasped  so 
that  the  fundus  rests  in  the  palm  of  the  hand,  with  the  fingers  to  the 

*  For  historical  references,  vide  Riol,  "  Delivrance  par  expression,"  G.  Masson, 
1890;  MuNDE,  "Obstetric  Palpation,"  p.  103. 


216 


LABOR. 


front.  The  exercise  of  circular  compression  forces  the  placenta  from 
the  uterus,  or  in  case  of  failure  the  process  may  be  repeated  until  the 
object  is  accomplished.  It  is  true  that  the  expulsion  of  the  placenta 
will,  as  a  rule,  occur  spontaneously.  The  unaided  uterus  is,  how- 
ever, liable  to  relax,  and  become  the  source  of  haemorrhage  ;  or,  where 
the  delivery  does  not  take  place  speedily,  it  may,  on  the  other  hand, 
close  down,  so  as  to  imprison  the  placenta  within  its  cavity.  The  great 
merit  of  Crede's  method  is,  that  by  maintaining  retraction  it  prevents 
haemorrhage,  and  by  promoting  speedy  expulsion  it  guards  against 
the  dangers  of  retention.*  When  systematically  practiced,  the  bug- 
bear known  as  adherent  placenta  is  the  rarest  of  accidents.  The  prac- 
tice is  not  difficult,  and  is  devoid  of  danger.  To  be  successful,  how- 
ever, expression  should  be  practiced  only  during  a  contraction,  and  the 
propulsive  force  should  be  directed  from  the  fundus  downward  in  the 
axis  of  the  uterus.  Spiegelberg  f  lays  great  stress  on  exercising  com- 
pression of  the  uterus  from  the  moment  the  head  emerges  from  the 
vulva,  and  not  waiting  until  the  delivery  of  the  child  is  ended.  By 
so  doing,  general  contractions  are  maintained,  and  the  detachment  of 
the  placenta  promoted. 

The  evidence  of  the  expulsion  of  the  placenta  is  furnished  to  the 
operator  by  his  feeling  the  anterior  and  posterior  uterine  walls  in  con- 
tact with  one  another.  By  then  pressing 
the  uterus  downward  in  the  axis  of  the 
brim,  it  is  often  possible  to  drive  the  pla- 
centa into  the  vagina  and  through  the 
vulva.  There  is  no  objection,  however, 
at  this  stage,  to  expediting  delivery  by 
drawing  upon  the  cord  downward  and 
backward,  while  at  the  same  time  the 
uterine  pressure  is  maintained.  The  ex- 
traction of  the  placenta  should  take  place 
slowly,  to  avoid  tearing  the  membranes. 
As  the  placenta  passes  the  vulva  it  should 
be  made  to  revolve  so  as  to  twist  the  mem- 
branes into  a  cord,  which  should  be  with- 
drawn with  the  utmost  care.  If  the  mem- 
branes are  felt  to  give  way  at  any  point, 
the  fingers  should  be  introduced,  if  neces- 
sary, into  the  vagina  to  seize  them  above 
Fig.  131.— ShowinsT  the  effect  of  the  site  of  the  laceration,  and  the  re- 
Srdl'TschiuztT'  inoval  should  be  proceeded  with  by  gen- 

tle manipulations. 
When  the  mechanism  of  placental  delivery  is  not  interfered  with 
by  premature  tractions  upon  the  cord,  tlie  placenta  descends  edgewise 

*  KiOL,  loc.  ciL,  p.  34.  f  Spiegeluekg,  "  Lchrbucb,"  p.  192. 


CONDUCT  OF  NORMAL  LABOR. 


217 


through  the  cervix,  and  its  expulsion  is  effected  with  the  loss  of  but 
a  trifling  amount  of  blood.*  When  extraction,  on  the  contrary,  is  at- 
tempted previous  to  descent  by  pulling  upon 
the  cord,  the  central  portion  of  the  placenta 
is  dragged  into  the  cervix,  while  the  bor- 
ders are  inverted  in  such  a  way  as  to  form  a 
cup-like  cavity.  This  disturbance  of  the 
normal  mechanism  not  only  increases  the 
difficulty  of  delivering  the  placenta,  but 
causes  the  latter  to  exercise  a  suction  force 
which  increases  the  haemorrhage,  and  at 
times  even  is  capable  of  partially  inverting 
the  lax  uterine  walls.  Now  and  then,  where 
the  occlusion  of  the  cervix  is  complete,  it 
may  be  found  impossible  to  effect  delivery 
without  first  introducing  two  fingers,  and 
hooking  down  the  margin  of  the  placenta, 
so  as  to  allow  air  to  pass  above  into  the  uter- 
ine cavity. 

Caee  of  the  Patient  aptek  Delivery. 
As  the  dans^er  of  hsemorrhage  does  not 

^  T       •?!       1  ,1  1  •  ,1       i^'iG.  132. — Showing  normal  posi- 

always  end  with  placental  expulsion,,  the  tion  of  placenta.  (Duncan.) 
physician  should  be  ready  to  sacrifice,  even 

in  simple  cases,  at  least  a  half -hour  to  close  observation  of  the  subse- 
quent behavior  of  the  uterus.  The  weight  of  the  hand  laid  above  the 
symphysis  pubis  is  usually  sufficient  to  maintain  a  safe  degree  of  re- 
traction. Should,  however,  the  uterus  become  lax,  and  lose  its  out- 
line, the  physician  should  grasp  it  in  his  hand  and  knead  it  firmly 
until  a  contraction  is  excited.  In  this  way  he  not  only  guards  against 
haemorrhage,  but,  by  preventing  the  formation  of  clots,  he  diminishes 
in  multiparae  the  severity  of  the  after-pains. 

Most  physicians  seek  additional  security  against  haemorrhage  by 
administering  ergot,  which,  as  is  well  known,  favors  tonic  retraction  of 
the  uterus.  To  this  there  is  no  objection,  provided  the  ergot  be  given 
subsequent  to  the  expulsion  of  the  placenta.  When  given,  as  is  com- 
monly done,  at  the  time  of  the  passage  of  the  child's  head,  it  is  liable 
to  produce  its  effect  prematurely,  and  thus  to  give  rise  to  hour-glass 
contraction.  The  rarity  of  the  accident  is  no  argument  in  favor  of 
th3  popularity  of  the  practice,  in  the  face  of  the  serious  complication 
to  which  it  is  capable  of  giving  rise.  When  the  physician  judges  it  is 
safe  to  suspend  the  prophylactic  pressure  upon  the  uterus,  he  should 
see  that  all  the  soiled  clothing  be  removed  from  beneath  his  patient, 
and  that  the  nurse  wash  the  genitalia  gently  but  thoroughly.  Nothing 
*  Matthews  Duncan,  "  Edinburgh  Med.  Jour.,"  April,  1871. 


218 


LABOR. 


does  so  much  to  cause  speedy  disappearance  of  the  soreness  of  the  ex- 
ternal parts  as  perfect  cleanliness.  In  hospitals  a  vaginal  douche  of 
warm  carbolized  water  should  be  combined  with  external  ablutions. 
The  perinaeum  should  then  be  carefully  examined,  and,  if  lacerations 
are  discovered,  the  physician  should  make  himself  acquainted  with 
their  extent  and  importance. 

The  apj)lication  of  the  binder  after  delivery  is  one  of  those  points 
in  practice  about  which  men  of  large  experience  entertain  a  difference 
of  opinion.  In  my  sttident-days  in  the  Hopital  des  Cliniques  in  Paris, 
the  binder  was  dispensed  with.  A  folded  sheet  was,  however,  laid 
across  the  abdomen,  it  having  been  found  that  a  certain  amount  of 
pressure  was  necessary  for  the  comfort  of  the  patient.  This  plan 
compelled  her  to  lie  upon  her  back,  and  thus  had  the  disadvantage 
of  restricting  freedom  of  movement.  Careful  observation  has  failed, 
however,  to  show  me  a  single  good  reason  why  the  binder  should  be 
discarded.  When  properly  applied,  it  adds  greatly  to  the  woman's 
comfort,  and  enables  her  to  turn  at  will  upon  her  side.  My  own  pref- 
erence is  for  a  piece  of  unbleached  mvislin  wide  enough  to  reach  below 
the  hips. 

In  adjusting  the  binder  the  physician  should  place  himself  to  the 
right  of  the  woman  ;  he  should  seize  the  near  end  between  the  thumb 
and  two  fingers  of  the  left  hand,  while  with  the  right  hand  he  draws 
the  farther  portion  smoothly  over  it.  The  two  ends  should  then  be 
held  with  the  left  hand,  and  the  pins,  which  should  preferably  be  of 
large  size,  should  be  inserted  with  the  right.  The  process  should  be- 
gin below,  and  be  followed  upward  at  intervals  of  about  two  inches. 
These  details  are  given  because  the  writer  remembers  his  own  embar- 
rassment arising  from  his  inability  to  get  information  upon  this  trivial 
subject  in  the  early  days  of  his  practice.  Moreover,  as  many  women 
are  somewhat  tenacious  of  having  the  binder  first  applied  by  the  physi- 
cian, to  know  how  to  do  it  with  address  is  not  an  indifferent  accom- 
plishment. Many  place  a  compress  made  of  a  folded  towel  above  the 
symphysis  pubis.  This  addition  usually  serves  no  better  purpose  than 
to  displace  the  uterus  to  one  side.  The  toilet  of  the  patient  is  finally 
completed  by  laying  a  warm  folded  napkin  at  the  vulva  to  receive  the 
lochial  discharge. 

Treatment  of  Perineal  and  Cervical  Lacerations. — It  is  needless,  as 
we  have  already  stated,  to  invade  the  domain  of  gynaecology  to  explain 
the  serious  after-results  of  neglected  perineal  and  cervical  lacerations. 
During  childbed,  open  wounds  in  the  course  of  the  genital  canal  are  a 
source  of  danger  from  septic  infection,  and,  even  when  kept  clean  by 
frequent  carbolized  douches,  retard  the  progress  of  recovery.  The  art 
of  closing  lacerations  of  significant  extent  by  suture  deserves,  there- 
fore, to  be  acquired  by  every  obstetric  practitioner.  While  in  hospital 
practice  the  results  as  regards  immediate  union  are  widely  variable, 


CONDUCT  OF  NORMAL  LABOR. 


219 


and  often,  in  consequence  of  atmospheric  conditions,  are  negative,  in 
properly  conducted  labors  occurring  in  private  practice,  where  the 
hygienic  conditions  are  favorable,  failure  to  obtain  union  is  a  rare 
exception.  The  details  of  the  operative  procedures  will  be  given  in 
connection  with  the  pathology  of  labor. 

Anesthetics  ii^  Midwifery. 

The  value  of  anaesthetics  in  certain  irregularities  of  the  labor- 
pains,  in  eclampsia,  and  in  most  midwifery  operations,  is  no  longer  a 
matter  of  discussion.  The  benefits  from  their  employment  in  such 
cases  are  palpable  and  beyond  dispute.  As  to  the  right,  however, 
of  a  woman  to  have  her  sufferings  assuaged  in  ordinary  normal  labor, 
there  is  by  no  means  unanimity  of  opinion.  To  be  sure,  the  old  ob- 
jections raised  in  Sir  James  Simpson's  day  that  labor-pain  is  a  salutary 
manifestation  of  life-force,  that  anaesthesia  gives  rise  to  paralysis,  to 
peritonitis,  to  puerperal  mania,  to  haemorrhage,  to  pericardial  adhe- 
sions, to  indecencies  of  language  and  behavior,  and  that  it  contravenes 
the  word  of  God,  are  now  known  to  be  unfounded  or  imaginary .  Still, 
there  is  no  doubt  that  the  vast  majority  of  medical  men  refrain  from 
the  use  of  anaesthetics  in  ordinary  labor,  either  from  vain  apprehen- 
sions or  because  some  incident  in  their  practice  has  led  them  to  sus- 
pect that,  in  spite  of  statistics,  they  are  not  devoid  of  objectionable 
or  dangerous  properties.  In  my  own  experience  during  the  last  sixteen 
years  there  have  been  comparatively  few  cases  in  which  I  have  not 
used  chloroform  or  ether  in  some  stage  of  labor.  The  result  of  my 
experience  has  been  to  make  me  a  warm  advocate  of  their  wider  em- 
ployment on  the  one  hand,  while  proclaiming  the  necessity  of  caution 
in  their  use  upon  the  other.  It  seems  to  me  that  the  hesitancy  mani- 
fested regarding  their  general  adoption  is  due,  in  large  measure,  to  the 
fact  that  few  practitioners  give  themselves  the  trouble  to  master  the 
necessary  modus  operandi,  to  study  the  limitations  of  their  usefulness, 
or  to  learn  the  conditions  of  their  safe  administration.  It  should  be 
steadfastly  borne  in  mind  that  the  giving  of  anaesthetics  in  labor  is  an 
art  to  be  acquired — a  very  simple  one,  perhaps,  but  the  practice  of 
which  admits  of  neither  ignorance  nor  carelessness. 

As  in  ordinary  surgical  practice,  anaesthetics  are  contraindicated  by 
organic  affections  of  the  heart  and  lungs. 

Except  in  the  prolonged  insensibility  required  for  difficult  obstet- 
rical operations,  I  think  the  preference  should  be  accorded  to  chloro- 
form rather  than  to  ether.  The  former  possesses  the  advantage  of 
being  more  agreeable,  more  manageable,  and  more  rapid  in  its  action. 

Anaesthesia,  not  narcosis,  is  the  object  aimed  at,  and  the  dulling 
of  the  sensibility  is  much  more  readily  effected  by  chloroform  than  by 
ether. 

As  a  rule,  chloroform  should  not  be  administered  during  the  first 


220 


LABOR. 


stage  of  labor,  partly  because  of  its  tendency,  when  given  at  too  early 
a  period,  to  weaken  the  contractions  of  the  uterus,  and  partly  because 
protracted  anaesthesia  has  a  tendency  to  impair  the  cardiac  force.  To 
this  rule  there  are,  however,  numerous  exceptions,  to  which  we  shall 
have  occasion  to  revert  in  connection  with  the  consideration  of  irreou- 

o 

lar  labor-pains. 

If  the  pains  in  the  second  stage  are  of  feeble  intensity,  it  is  best  to 
withhold  the  anaesthetic  ;  if  of  normal  strength,  chloroform  may  be 
given,  but  at  first  only  in  small  doses  and  during  the  continuance  of  a 
pain.  The  anaesthetic  should  not  be  pushed  to  the  stage  of  complete 
unconsciousness  until  the  head  begins  to  emerge  at  the  vulva. 

Chloroform  can  be  conveniently  given  upon  a  folded  handkerchief. 
The  latter  should  be  held  near  to,  but  not  in  contact  with,  the  respir- 
atory passages.  The  best  diluent  for  chloroform,  as  was  long  ago 
stated  by  Sir  James  Simpson,  is  atmospheric  air.  If  the  handkerchief 
be  laid  directly  across  the  nose,  instant  suspension  of  respiration  may 
result.  A  minor  evil  is  the  cutaneous  irritation  produced  by  placing 
the  chloroform  in  direct  contact  with  the  lips  and  mouth. 

At  the  beginning  of  each  pain  the  patient  should  be  directed  to 
take  a  number  of  deep  inspirations.  During  the  acme  of  the  pain  the 
expiratory  efforts  which  are  then  called  into  play  prevent  the  inhala- 
tion of  any  considerable  amount  of  the  anaesthetic. 

When  the  head  presses  upon  the  perinaeum,  the  handkerchief  should 
be  intrusted  to  the  nurse,  but  the  administration  to  the  end  should  be 
directed  and  strictly  supervised  by  the  physician. 

When  chloroform  is  first  given,  it  is  common  for  the  pains  to 
become  weakened,  but  this  suspensive  influence  upon  the  uterus 
is  usually  temporary.  Exceptionally,  however,  the  weakness  of  the 
pains  may  continue,  and  render  it  necessary  to  withhold  the  anaes- 
thetic. In  still  rarer  cases  the  pains  remain  inefficient  after  the  anaes- 
thesia has  subsided.  On  this  account  it  seems  to  me  certain  that  those 
who  use  chloroform  habitually  will  find  themselves  compelled  to  resort 
to  the  forceps  with  somewhat  increased  frequency.  A  tardy  labor,  due 
to  uterine  inertia,  will  likewise  call  for  additional  vigilance  during  the 
stage  of  placental  expulsion,  to  forestall  the  occurrence  of  hgemorrhage. 

The  immunity  enjoyed  by  women  in  childbirth  against  the  acci- 
dents which  sometimes  occur  from  anaesthesia  in  surgical  practice  is 
not  absolute,  but  dependent  upon  its  cautious  and  intelligent  adminis- 
tration. I  once  narrowly  escaped  losing  a  patient  in  the  Bellevue 
Hospital,  upon  whom  I  designed  to  perform  version,  in  consequence  of 
my  house-physician  suddenly  crowding  a  paper  funnel  containing  a 
towel  wet  with  chloroform  over  the  respiratory  passages. 

Chloroform  should  not  be  given  in  the  third  stage  of  labor.  The 
relative  safety  of  chloroform  in  parturition  ceases  with  the  birth  of 
the  child.    After  delivery  it  favors  the  relaxation  of  the  uterus,  and 


MULTIPLE  PREGNANCIES  AND  THEIR  MANAGEMENT.  221 


predisposes  to  haemorrhage.  Moreover,  after  the  uterus  has  been 
emptied  there  is  always  an  increase  of  blood  in  the  large  vessels  of  the 
abdomen,  and  a  corresponding  recession  of  blood  from  the  head. 
Now,  it  is  known  that  the  quantity  of  chloroform  which  one  day  is  per- 
fectly tolerated  by  an  individual  in  health  may  prove  fatal  on  the  suc- 
ceeding day,  in  case  of  the  intervention  of  any  considerable  loss  of  blood. 
Cerebral  anaemia,  from  any  cause,  increases  the  risk  of  anaesthesia. 

In  lengthy  operations  requiring  prolonged  anaesthesia,  ether,  as  has 
already  been  intimated,  should  be  preferred  to  chloroform. 


CHAPTER  XII. 

MULTIPLE  PREGNANCIES  AND  THEIR  MANAGEMENT. 

Frequency. —  Origin. — Varieties} — Acardia. — Weight. — Unequal  development.— Superfe- 
tation. — Diagnosis. — Labor. — Presentations. — Simultaneous  entrance  of  both  children 
into  the  pelvis. — Locking. — Prognosis. — Conduct  of  labor. 

The  term  multiple  pregnancy  is  used  when  more  than  one  germ 
are  simultaneously  developed.  Twins,  the  most  common  form,  occur 
in  the  proportion  of  one  to  between  eighty  and  ninety  births  ;  triplets 
in  about  the  proportion  of  one  to  seven  thousand  ;  quadruplets  and 
quintuplets  are  of  extreme  rarity.  No  authentic  example  of  over  five 
children  at  a  birth  is  on  record.  An  instance  of  quintuplets  I  have 
once  witnessed.  In  the  Prussian  statistics  of  Von  Hemsbach  and 
Veit,  based  upon  thirteen  million  births,  the  number  of  twin  pregnan- 
cies amounted  to  150,000.  Of  these,  in  50,000  both  children  were 
boys  ;  in  46,000  both  were  girls ;  and  in  54,000  the  children  consisted 
of  a  boy  and  a  girl. 

Twins  may  develop  either  from  two  distinct  ova,  discharged  from 
the  same  or  from  distinct  Graafian  follicles,  or  may  both  originate  from 
a  single  ovum.  If  two  Graafian  follicles  rupture,  the  ovaries  will 
offer  two  corpora  lutea.  In  some  instances  a  corjius  luteum  has  been 
found  in  eacli  ovary  ;  in  others,  both  are  situated  in  the  same  ovary. 

In  the  case  where  twins  develop  from  two  ova,  each  foetus  is  con- 
tained in  its  own  chorion.  If  the  ova  are  imbedded  in  the  decidua 
at  sufficiently  distant  points,  the  placentae  will  be  separate,  and  each 
ovum  will  have  its  distinct  reflexa.  If  near  one  another,  the  placentae 
are  often  united  at  their  borders,  each,  however,  maintaining  its  inde- 
pendent circulation.  In  some  cases  the  two  ova  lie  so  close  together 
that  they  are  encircled  by  a  common  reflexa. 

When  twins  are  developed  from  two  centers  of  development  con- 
tained in  the  same  ovum,  the  placenta,  the  chorion,  and  reflexa  are,  of 
course,  common  to  both.    In  most  instances,  each  foetus  is  contained 


222 


LABOR. 


in  its  own  amnion.  Occasionally,  however,  twins  are  furnished  with 
but  one  amnion,  a  peculiarity  which,  in  some  cases  at  least,  is  not 
primary,  but  the  result  of  an  absorption  of  the  party-wall  between  two 
originally  distinct  cavities.* 

Twins  from  the  same  ovum  are  always  of  the  same  sex.  Anasto- 
moses of  greater  or  less  extent  exist  between  the  placental  vessels  of 
the  two  embryos.  The  consequences  of  these  communications  are  of 
the  utmost  importance,  for,  when  extensive,  the  heart's  action  in  one 


Fio.  133.— Author's  case  of  acardia;  the  monstrosity  weigrhed  three  pounds  nine  ounces; 
there  were  no  traces  of  heart,  lungs,  pancreas,  liver,  spleen,  or  sternum. 

foitus  counterbalances  that  of  the  other  ;  the  stronger  blood-current  in 
the  placenta  pushes  back  the  weaker  one,  at  first  impeding  the  circula- 

*  AnLFELD,  "  Bcitriigc  zur  Lehre  von  den  Zwillingcn,"  "  Arch.  f.  Gynack.,"  Bd.  vii,  p. 
281. 


MULTIPLE  PREGNANCIES  AND  THEIR  MANAGEMENT.  223 


tion  of  the  less  favored  foetus,  then  arresting  it,  and  finally  causing  it 
to  reverse  its  direction.  The  heart  atrophies,  and  an  acardia  is  pro- 
duced, which  is  simply  an  appendage  to  the  healthy  foetus.  The  cir- 
culation in  the  acardia  takes  place  as  follows  :  Venous  blood  from  the 
healthy  foetus  is  conveyed  by  the  umbilical  arteries  to  the  placenta  ; 
the  force  of  the  fetal  heart  drives  the  stream  through  the  communi- 
cating branches  to  the  umbilical  arteries  of  the  less  favored  twin  ;  this 
force  is,  however,  insufficient  to  carry  the  current  to  the  upper  parts 
of  the  body,  which  are,  therefore,  not  developed.  The  favorable  posi- 
tion of  the  lower  extremities  for  receiving  the  blood  from  the  umbili- 
cal vessels  explains  their  continued  though  imperfect  growth  and  de- 
velopment. The  blood  carried  to  the  foetus  by  the  umbilical  arteries  is 
returned  by  the  umbilical  vein. 

According  to  Ahlfeld,*  a  division  may  take  jolace  in  the  formative 
material  contained  within  a  single  area  germinativa.  This  division 
may  be  complete,  and  thus  produce  separate  twins  inclosed  in  the 
same  amnion,  which  not  only  are  of  the  same  sex,  but  bear  to  one 
another  through  life  the  most  striking  similarity  as  regards  appear- 
ance, physical  peculiarities,  and  both  mental  and  moral  characteris- 
tics ;  or  it  may  be  incomplete,  and  thus  give  rise  to  conjoined  twins, 
or  one  of  the  numerous  forms  of  double  monsters. f 

In  triplets  it  is  common  to  find  one  child  derived  from  an  indepen- 
dent ovum,  and  two  from  a  single  ovum.  In  a  case  of  quadruplets 
reported  by  P.  Muller,  J  two  ova  were  simple,  while  the  third  contained 
two  embryos.  The  children  in  the  single  ova  were  of  the  female, 
while  those  in  the  double  ovum  were  of  the  male  sex. 

The  average  weight  of  the  individual  children  in  multiple  preg- 
nancies is  less  than  that  of  children  born  single.  This  is  partly  due 
to  the  frequency  with  which  the  excessive  distention  of  the  uterus 
becomes  the  exciting  cause  of  premature  delivery,  and  partly  to  the 
obvious  fact  that  the  maternal  organism  is  rarely  capable  of  furnishing 
the  nutritive  material  requisite  for  the  complete  growth  of  more  than 
a  single  child. 

Twins  often  exhibit  at  birth  a  remarkable  disparity  as  regards  both 
size  and  development,  a  disparity  unquestionably  due  to  local  condi- 
tions. A  striking  example  of  this  is  shown  in  a  case  related  by 
Schultze.*    One  child,  at  the  time  of  delivery,  was  nearly  if  not  quite 

*  Ahlfeld,  "  Die  Entstehung  der  Doppelbildung  und  der  homolcgcn  Zwillinge,"  "Arch, 
f.  Gynaek.,"  Bd.  ix,  p.  196. 

f  Schultze,  on  the  other  hand,  contends  that  the  double  monsters  are  derived  from  the 
fusion  of  two  embryos  developed  upon  the  blastodermic  vesicle  at  points  close  to  one  an- 
other. Schultze,  "  Ucbcr  Zwillingsschwangerschaft,"  Volkmann's  "Samm.  klin.  Vortr." 
No.  34. 

X  p.  MuLLER,  "Eine  Vierling's  Gcburt,"  "Ztsehr.  f.  Geburtsh.  und  Gynaek.,"  Bd.  iii, 
p.  166. 

*  Schultze,  loc.  cit.^  p.  308. 


224 


LABOR. 


mature,  while  the  other  presented  the  appearances'  of  a  six  weeks' 
foetus.  As  hoth  ova  were  enveloped  in  the  same  reflexa,  their  develop- 
ment must  have  begun  at  nearly  the  same  time. 

Sometimes  on.e  foetus  dies,  and  yields  to  the  more  fortunate  broth- 
er the  space  and  the  nutritive  material  which  would  otherwise  have 
fallen  to  his  share.  In  such  a  case  the  ovum  and  the  contained  foetus 
may  be  compressed  by  the  surviving  twin,  and  be  flattened  against  the 
uterine  wall,  giving  rise  to  the  so-called  foetus  papyraceus"  ;  or  it 
may  degenerate  into  a  mole  ;  or  the  aborted  ovum  may  be  expelled, 
while  the  living  foetus  advances  to  the  full  term  of  gestation. 

Very  rarely,  where  the  twins  are  both  living,  but  have  undergone 
unequal  development,  the  stronger  child  may  be  delivered  first,  while 
the  other  remains  in  the  uterus,  and  is  born  after  weeks  of  delay,  dur- 
ing which,  under  more  favorable  conditions,  it  makes  good  the  defi- 
ciencies due  to  its  retarded  evolution.  The  most  remarkable  cases  of 
this  kind  occur  in  the  uterus  duplex.  Professor  Fordyce  Barker  re- 
lates an  instance  in  his  practice  where,  in  a  double  uterus,  a  mature 
living  male  child  was  born  on  the  lOtli  of  July,  1855,  and  on  the  22d 
of  September  following  the  mother  gave  birth  to  a  full- term  living  girl. 

Histories  like  the  foregoing  are  often  adduced  in  support  of  the 
theory  of  what  is  known  as  superfetation,  a  theory  which  supposes 
that,  after  conception  has  once  occurred,  a  second  gestation  may  result 
from  a  subsequent  coitus.  That  this  is  possible,  if  two  ova  are  de- 
tached during  the  same  menstrual  period,  seems  to  be  established  by 
authentic  accounts  of  negro  women  giving  birth  to  twins,  showing  the 
evidences  of  a  paternity  derived  in  one  from  the  black  and  in  the 
other  from  the  white  race.  That  impregnation  can  take  place  at  two 
periods  distant  from  one  another  must  be  regarded  as  an  inadmissible 
hypothesis,  until  physiologists  shall  succeed  in  demonstrating  in  a  sin- 
gle instance,  by  the  presence  of  corpora  lutea  of  different  ages,  that 
ovulation  ever  occurs  during  pregnancy. 

Diagnosis. — The  diagnosis  of  multiple  pregnancy  is  rarely  to  be 
made  out  with  absolute  certainty.  Unusual  size  of  the  uterus,  with 
exaggeration  of  the  symptoms  which  result  from  pressure,  would  nat- 
urally lead  to  inquiry  on  the  part  of  the  physician,  as  it  is  certain  to 
excite  apprehensions  in  the  mind  of  the  pregnant  female.  Size,  how- 
ever, furnishes  but  an  uncertain  criterion,  as  it  may  be  equally  due  to  the 
presence  of  a  very  large  child,  or  to  an  excess  of  amniotic  fluid.  More 
trustworthy  information  is  to  be  obtained  from  palpation  and  auscul- 
tation. Thus  the  recognition  of  a  number  of  distinct  fetal  parts  and 
the  exclusion  of  hydramnion  would  render  the  diagnosis  of  twin  preg- 
nancy probable.  The  outlining  of  two  fetal  heads  at  a  distance  from 
one  another  would  make  the  diagnosis  certain.  When  the  fetal  heart 
is  heard  at  two  remote  points,  and  the  sound  is  found  to  die  away  in- 
the  intervening  space,  it  is  justifiable  to  conclude  that  the  sound  at 


MULTIPLE  PREGNANCIES  AND  THEIR  MANAGEMENT. 


225 


each  point  has  a  separate  origin.  If  the  two  heart-beats  are  counted 
at  the  same  time  by  different  observers,  and  are  found  not  to  corre- 
spond in  frequency,  a  twin  pregnancy  is  established  beyond  dispute. 
After  the  birth  of  the  first  child,  the  presence  of  the  second  is  deter- 
mined by  the  size  and  consistence  of  the  uterus,  and  the  perception  of 
fetal  parts  both  through  the  abdominal  walls  and  the  vagina. 

The  recognition  of  triplets  and  quadruplets  is,  of  course,  attended 
with  even  greater  difficulties  than  that  of  twins. 

Labor  in  Multiple  Pregnancies. — We  have  already  noticed  the  fre- 
quency of  premature  labor  in  multiple  pregnancies.  Of  one  hundred 
and  ninety-two  twin  births  reported  by  Eeuss  *  from  the  Wiirzburg 
clinic,  fifty-one  did  not  complete  the  full  term  of  gestation.  In  one 
of  these  abortion  resulted  from  small-pox,  in  another  from  syphilis, 
in  two  cases  premature  labor  was  induced  artificially,  in  the  others 
labor  occurred  spontaneously — in  one  instance  at  the  seventh  month, 
in  the  others  in  the  ninth  and  tenth  months. 

Twin  labors  are  usually  easy.  The  first  child  is  delivered  as  in 
simple  labors,  and,  except  in  faulty  presentations,  is  followed  shortly 
by  the  second.  The  interval  varied,  in  seventy-four  of  Reuss's  cases 
which  terminated  spontaneously,  from  five  minutes  to  one  and  a. half 
hour.  In  seventy-nine  per  cent,  the  interval  was  less  than  an  hour. 
As  the  stage  of  dilatation  is  completed  at  the  time  of  the  expulsion  of 
the  first  twin,  a  protracted  interval  is  occasioned  purely  by  weakness 
and  inefficiency  of  the  pains. 

The  placentae  are  usually  expelled  after  the  birth  of  the  second 
child  ;  now  and  then  the  placenta  of  the  first  child  precedes  the  birth 
of  the  second  ;  again,  the  second  child  may  not  be  born  until  after  the 
delivery  of  its  placenta.  AVhen  the  placentae  are  united,  a  portion  may 
be  torn  off  and  expelled  with  the  first  child,  while  the  remainder  is  not 
thrown  off  until  after  the  birth  of  the  second,  f  The  placental  stage 
is,  owing  to  the  relaxed  state  of  the  uterine  walls,  apt  to  be  of  longer 
duration  than  in  simple  labors,  and  calls  for  the  exercise  of  special 
care  to  guard  against  the  occurrence  of  haemorrhage. 

Presentations  in  Twin  Labors. — Spiegelberg  I  furnishes  the  follow- 
ing table,  derived  from  1,138  deliveries,  of  which  899  were  taken  from 
Kleinwachter  and  203  from  Eeuss  : 


Both  heads  presenting  558  or  49  per  cent. 

Head  and  breech  presenting  361  "  31-7  " 

Both  pelvic  presentations   98  "    8-G  " 

Head  and  transverse  presentations   71  "    6-18  " 

Breech  and  transverse   46  "    4-14  " 

Both  transverse   4  "    0'35  " 


*  Reuss,  *'^Zur  Lehre  von  den  Zwillingen,"  "  Arch.  f.  Gynaek.,"  Bd.  iv,  p.  123. 
f  Vide  Spiegelberg,  "  Lehrbuch  dcr  Gcburtshiilfe,"  Bd.  i,  p.  203. 
X  Ibid. 

15 


226 


LABOR. 


Fig.  134. — Twin  pregnancy,  botli  heads  presenting.    (Tarnier  et  Chantreuil.) 

The  transverse  presentations  are  mostly  secondary,  consequent 
upon  the  roominess  of  the  uterine  cavity  and  the  sudden  escape  of 
the  amniotic  fluid.  Version  is,  of  course,  in  such  cases  easily  per- 
formed. 

The  Simultaneous  Entrance  of  Both  Children  into  the  Pelvis.— The 

consideration  of  the  various  complications  to  which  this  anomaly  gives 
rise  belongs  properly  to  the  domain  of  pathology.  To  avoid,  however, 
needless  repetitions,  they  may,  for  convenience'  sake,  be  properly  con- 
sidered in  the  present  connection. 

When  both  children  present  at  the  brim  previous  to  the  rupture  of 
the  membranes,  it  usually  happens  that,  with  the  escape  of  the  amni- 
otic fluid,  one  of  the  twins  descends  into  the  pelvis,  while  the  second 
glides  to  one  side.  The  result  is  identical,  whether  the  twins  are  con- 
tained in  a  single  or  in  separate  sacs.  If  interference  is  called  for 
because  of  delay,  the  amnion,  or  one  amnion  in  case  there  are  two, 
should  be  ruptured,  and  the  nearest  presenting  part  brought  into  the 
pelvis,  while  tlie  other  is,  at  the  same  time,  pushed  out  of  the  way. 


MULTIPLE  PREGNANCIES  AND  THEIR  MANAGEMENT.  227 


If  head  and  breech  present,  the  head  should  preferably  be  allowed  to 
descend  first. 

It  may  happen,  however,  that,  after  rupture,  both  children  may 
descend  into  the  pelvis  so  close  to  one  another  as  to  hinder  each  the 
other  in  its  further  progression.  This  locking  of  the  twins,  as  it  is 
termed,  may  take  place  in  one  of  two  ways,  viz.  : 

1.  In  double  vertex  presentations,  delivery  may  be  impeded  by  the 
pressing  of  the  second  head  into  the  neck  of  the  more  advanced  foetus, 
or,  after  the  birth  of  the  first  head,  the  second  may  enter  the  pelvis 
and  arrest  the  advance  of  the  thorax.  Obviously  this  difficulty  could 
only  arise  in  a  case  where  both  heads  were  of  unusually  small  size. 
The  diagnosis  has  rarely  been  made  previous  to  the  birth  of  the  first 
head.  The  treatment  consists  in  the  artificial  extraction  of  one  head 
after  the  other,  and  then  delivering  the  body  of  the  first  child.  Cra- 
niotomy is  usually  not  necessary.  The  prognosis  as  regards  the  chil- 
dren is  extremely  unfavorable.    Reimann  *  reports  six  cases  in  which 


Fio.  135.— Twin  pregnancy,  head  and  breech  presenting.    (Tarnier  ct  Chantreuil.) 
*  Reimann,  "  Am.  Jour,  of  Obstct.,"  1811,  vol.  i,  p.  58. 


228 


LABOR. 


the  fate  of  the  children  was  known.  Of  the  six  first-born,  one  sur- 
vived ;  of  the  six  last-born,  two  survived.  Reimann,  in  commenting 
on  these  figures,  remarks,  The  child  whose  head  first  enters  the  pel- 
vis is  in  great  danger,  because,  not  only  is  its  neck  squeezed  by  the 
head  of  the  second  child,  thereby  producing  cerebral  hyperaemia,  but 
its  umbilical  cord  is  exceedingly  liable  to  be  compressed  by  the  body 
of  the  second  child. ' ' 

2.  When  one  child  presents  by  the  breech,  the  other  by  the  vertex, 
the  former,  because  of  its  smaller  size,  is  apt  to  descend  first  into  the 
pelvis.  No  difficulty  is  then  experienced  until  the  neck  is  born.  In 
case,  however,  meantime  the  head  of  the  second  child  has  entered  the 
pelvis,  further  progress  may  be  rendered  impossible,  a  lock  resulting 
either  from  the  overlapping  of  the  chins,  or  of  the  occipital  portions 
of  the  two  heads,  or  from  the  pressure  of  the  face  of  one  child  into 
the  neck  beneath  the  occiput  of  the  other.  By  lifting  the  body  of  the 
child,  and  introducing  the  half-hand  into  the  vagina,  the  diagnosis  is 
rendered  easy. 

In  a  large,  roomy  pelvis,  if  the  pains  are  good  and  the  children 
small,  spontaneous  delivery  may  take  place.  In  a  number  of  cases  of 
this  kind  which  have  been  reported,  the  head  of  the  second  child  was 
born  first.  In  a  few  instances,  it  has  been  found  possible  to  push  up 
the  second  head.  Operative  measures  consist  in  applying  the  forceps 
and  extracting  the  second  head,  and  afterward,  if  necessary,  the  first. 
In  case  of  failure,  craniotomy  remains  as  an  ultimate  resort.  The  first 
child  is  rarely  born  living.  Of  twenty-six  children,  the  fate  of  which 
was  ascertained  by  Eeimann,  only  three  survived.  The  prognosis  of 
the  second  child  is  more  favorable.  Of  twenty-nine  cases,  Reimann 
reports  nineteen  survivals.  Naturally,  therefore,  the  perforation  of 
the  first  head  would  be  preferred,  were  the  matter  one  purely  of  elec- 
tion, but  the  operation  is  very  difficult,  and  does  not  remove  the  ob- 
stacle, for  even  the  diminished  head  can  not  pass  the  one  already 
occupying  the  pelvis.*  In  the  cases  so  far  reported,  where  decapita- 
tion of  the  first  child  has  been  performed,  the  operation  has  not  proved 
successful  in  saving  the  life  of  the  second. 

The  possibility  of  one  twin  sitting  astride  the  other  when  trans- 
verse requires  mention,  because  of  the  perplexity  that  may  arise  as  to 
the  diagnosis,  unless  the  hand  is  introduced  into  the  lower  segment 
of  the  uterus  to  determine  the  exact  relations  of  the  twins  to  one 
another. 

Prognosis. — The  prognosis,  both  as  regards  the  children  and  the 
mother,  is  much  more  unfavorable  than  in  simple  labors.  Statistics 
on  this  point  are  valueless,  as  much  depends  upon  the  conduct  of  the 
physician.  As  regards  the  children,  the  increased  mortality  results 
from  prematurity,  from  unequal  development,  and  from  the  frequency 
*  Reimann,  loc.  cif.,  p.  61. 


MULTIPLE  PREGNANCIES  AND  THEIR  MANAGEMENT.  229 


of  malpositions  and  malpresentations,  requiring  operative  interference  ; 
as  regards  the  mother,  the  mortality  and  susceptibility  to  puerperal 
diseases  are  augmented  by  the  excessive  distention  of  the  uterus,  the 
extent  of  the  placental  wound,  the  feebleness  in  many  cases  of  uterine 
retraction  after  delivery,  and  by  the  operations  which  grow  out  of  the 
anomalies  to  which  labor  in  multiple  pregnancies  is  subjected. 

Conduct  of  Labor  in  Multiple  Pregnancies. — The  management  of 
multiple  pregnancies  does  not  differ  essentially  from  that  of  ordinary 
labor.  After  the  birth  of  the  first  child,  the  placental  end  of  the  cord 
should  in  all  cases  be  tied,  on  account  of  the  frequency  with  which 
anastomoses  are  found  between  the  vessels  of  the  placentae.  A  period 
of  repose  should  then  be  allowed,  to  enable  the  uterus  to  retract  down 
upon  the  remaining  ovum.  During  the  birth  of  the  second  child, 
every  care  should  be  taken  to  follow  the  uterus  with  the  hand,  and 
redoubled  precautions  should  be  observed  against  the  occurrence  of 
haemorrhage,  to  which  the  woman  is  exposed  both  on  account  of  the 
large  size  of  the  placental  wound  and  the  disposition  to  relaxation. 
Expression  should  be  employed  to  force  the  placentae  into  the  vagina. 
When  both  descend  at  once,  if  it  is  necessary  to  make  tractions,  both 
cords  should  be  drawn  upon,  simultaneously  or  in  alternation,  to  find 
which  placenta  is  most  easily  removed.  When  the  placenta  follows 
the  birth  of  the  first  child,  it  should  be  left  untouched  until  the  ad- 
vent of  the  second.    Vigilance  after  delivery  should  be  long  observed. 

We  have  already  noticed  that  the  length  of  time  between  the  ex- 
pulsion of  twins  situated  in  separate  membranes  rarely  exceeds  an 
hour.  When,  therefore,  there  is  a  longer  delay  in  the  delivery  of  the 
second  child,  measures  should  be  employed  to  excite  pains,  and  the 
membranes  should  be  ruptured.  In  case  of  a  premature  child  deliv- 
ered with  its  own  placenta,  cases  of  continued  development,  in  uterOy 
of  the  remaining  child,  would  point  to  the  policy  of  abstention.  In 
instances  where  more  than  two  children  are  contained  in  the  uterus, 
the  anomalies  of  position  are  more  frequent,  and  the  danger  of  haemor- 
rhage is  still  further  enhanced.* 

*  Spiegelberg,  "  Lchrbuch,"  pp.  206,  207. 


230 


THE  PUERPERAL  STATE. 


THE  PUEEPEEAL  STATE. 
CHAPTER  XIII. 

THE  PHYSIOLOGY  AND  MANAGEMENT  OF  CHILDBED. 

The  puerperal  state  borders  closely  upon  pathological  conditions. — Post-partum  chill. — 
Temperature. — The  pulse. — General  functions. — Retention  of  urine. — Loss  of  weight. 
— Involution. — Separation  of  the  decidua. — Closure  of  the  sinuses. — The  cervix. — 
The  vagina. — Position  of  uterus. — After-pains. — The  lochia. — The  secretion  of 
milk. — Anatomical  considerations. — Milk-fever. — Composition  of  milk.— Diagnosis 
of  the  puerperal  state. — The  new-bcyn  infant. — Changes  in  circulation. — The  navel. — 
Tumor  upon  the  presenting  part. — Digestion. — Skin. — Icterus. — Loss  of  weight. — 
Management  of  puerperal  state. — Sleep. — Passing  urine. — Visits  of  physician. — 
Washing  the  vagina. — Diet. — Laxatives. — Nursing. — Duration  of  lying-in  period. — 
Care  of  new-born  infant. — Bath. — Cord. — Nursing. — Wet-nurses, — Artificial  feeding. 

The  puerperal  state  occupies  the  border-land  between  health  and 
disease.  Though  in  a  strict  sense  physiological,  it  offers  a  variety  of 
conditions,  as  Schroeder  *  has  pointed  out,  which,  at  other  times,  and 
under  other  circumstances,  would  be  regarded  as  pathological.  Thus, 
the  exfoliation  of  the  decidua,  and  the  copious  serous  transudation, 
with  the  abundant  formation  of  young  cells  which  accompanies  the 
development  of  the  new  mucous  membrane,  would  elsewhere  be  re- 
garded as  characteristic  features  of  catarrhal  inflammation.  The  acute 
degeneration  of  the  uterus  presents  a  phenomenon  which,  when  re- 
peated in  any  other  organ  of  the  body,  would  prove  speedily  fatal. 
The  thrombus  formation  in  the  open  placental  vessels  possesses  no 
corresponding  physiological  analogue.  Again,  the  torn  vessels  may 
lead  to  haemorrhage,  while  the  traumata,  which  even  in  normal  labor 
result  from  parturition,  the  ease  with  which  deleterious  materials  are 
absorbed  by  the  wide  lymphatic  interspaces,  the  serous  infiltration  of 
the  pelvic  tissues,  the  exaggerated  size  of  the  lymphatics  and  veins, 
create  a  predisposition  to  innumerable  forms  of  disease.  The  nicety 
of  the  balance  between  normal  and  morbid  conditions  renders  it  pecul- 
iarly necessary  for  the  practitioner  to  make  himself  familiar  with  the 
physiological  limits  of  the  phenomena  of  childbed. 

Post-partum  Chill. — The  exertion  of  labor  is  followed  by  a  sense  of 
comfort  and  repose.  Often  after  the  birth  of  the  child,  a  chill  sets 
in  of  greater  or  less  intensity,  but  of  short  duration,  and  of  no  prog- 
nostic importance.  It  is  to  be  accounted  for  by  the  disturbance  of  the 
equilibrium  between  the  internal  temperature  and  that  of  the  external 
surface.  Thus,  toward  the  end  of  labor,  and  for  a  short  period  sub- 
sequent to  delivery,  the  loss  of  heat  is  increased  by  the  evaporation 

*  SciiKOEDKn,  "  Ilandbuch  dcr  Geburtshiilfc,"  6te  Aufl.,  p.  216. 


THE  PHYSIOLOGY  AND  MANAGEMENT  OF  CHILDBED. 


231 


from  the  lungs  and  skin,  and  the  cessation  of  muscular  effort.  This 
cooling  process  is,  however,  speedily  arrested  by  the  contraction  of  the 
cutaneous  arterioles.  During  the  period  which  intervenes  until  the 
external  and  internal  temperatures  rise  to  relatively  equal  levels,  the 
patient  experiences  chilly  sensations,  or  a  distinct,  well-defined  chill.* 
This  phenomenon  is  more  frequent  in  hypersesthetic  women  and  in 
those  w^hose  skins  are  bathed  in  profuse  perspiration,  especially  where 
there  has  been  some  necessary  exposure  of  the  person  during  the  ex- 
pulsion of  the  head  or  of  the  placenta.  Under  the  influence  of  a 
warm,  dry  bed,  the  chill  at  once  subsides. 

Temperature. — A  rise  of  temperature  follows  the  parturient  act, 
averaging  one  and  a  half  degree  in  primiparae,  and  one  degree  in  mul- 
tiparas. This  elevation  continues  during  the  first  six  days,  with,  how- 
ever, morning  remissions  and  slight  evening  exacerbations.  It  is  most 
pronounced  in  the  first  twelve  hours,  especially  when  they  coincide 
with  the  normal  evening  increment.  In  the  following  days  the  high- 
est point  is  usually  reached  at  five  in  the  afternoon,  while  the  lowest 
temperature  is  found  between  eleven  and  one  in  the  early  morning. 
A  temperature  of  100^°  belongs  within  physiological  limits.  My  own 
temperature-tables  confirm  amply  the  opinion  of  Schroeder,  that  a 
rise  above  100^°  is  by  no  means  incompatible  with  a  generally  satisfac- 
tory condition  of  the  patient.  Schroeder  attributes  the  increased  heat 
production  to  the  combustion  of  organic  substances  which  attends  the 
involution  of  the  uterus.  To  this  are  to  be  added,  as  provoking  causes, 
the  reaction  of  small  wounds  in  the  course  of  the  genital  canal,  and 
the  disturbances  attendant  upon  the  establishment  of  lactation,  f 

The  Pulse. — In  contrast  to  the  increase  in  the  temperature,  the 
pulse  often  exhibits  a  remarkable  diminution  in  frequency,  in  perfectly 
normal  cases  ranging  between  sixty  and  seventy  beats,  but  not  unfre- 
quently  dropping  to  a  still  lower  level,  and  may  even  sink  to  less  than 
forty  pulsations  in  the  minute.  This  slowing  of  the  pulse  is  of  favor- 
able prognostic  import.  It  is  known  to  be  associated  with  diminished 
arterial  tension,  J;  and  has  been  attributed  to  a  variety  of  not  very  sat- 
isfactory reasons,  such  as  the  sudden  removal  of  the  utero-placental 
vessels  from  the  circulation,  entailing  a  less  degree  of  labor  up6n  the 
heart,  repose  in  bed,  and  disturbed  action  of  the  pneumogastric  nerves. 
It  is  usually  most  marked  on  the  second  or  third  day,  and  does  not 
appear  to  be  specially  influenced  by  the  establishment  of  lactation. 

General  Functions. — During  the  first  week  the  skin  is  active  and 
moist ;  the  patient  is,  therefore,  sensitive  to  temperature  changes,  and 

*  Fehlisg,  "  Klin.  Bcobachtungen  iiber  den  Einfluss  dcr  todtcn  Friichtc  auf  die  Mut- 
ter," "Arch.  f.  Gynaek.,"  Bd.  vii,  p.  151. 

f  Vnle  Schroeder,  "  Schwangerschaft,  Geburt  und  Wochenbett,"  pp.  168-177  ;  Spiegel- 
berg,  "Lehrbueli,"  p.  210. 

X  Meyberg,  "Ucbcr  die  Pulse  dcr  Wochnerinnen,"  "Arch.  f.  Gynaek.,"  Bd.  xii,  p.  114. 


232 


THE  PUERPERAL  STATE. 


is  subject  to  profuse  perspiration  when  warmly  covered  or  during  sleep. 
The  appetite  is  lessened,  the  thirst  is  increased,  the  bowels  are  slug- 
gish, and  the  urine  abundant.  In  spite  of  the  light  diet  and  repose 
in  bed,  the  amount  of  urea  eliminated  is  but  slightly  diminished. 
Sugar  in  the  urine  is  observed  at  the  time  of  the  establishment  of  lac- 
tation. It  disappears  soon  afterward,  to  reappear,  however,  whenever 
the  milk  production  is  in  excess  of  its  consumption.*  The  diabetes 
is,  therefore,  due  to  absorption,  f 

.  Retention  of  Urine. — In  the  first  day  or  two  following  confinement, 
retention  of  urine  is  a  common  occurrence.  It  results,  according  to 
Schroeder,  from  the  increased  capacity  of  the  bladder  following  the  re- 
moval of  pressure  from  the  gravid  uterus.  Many  women,  who  suffer 
from  retention  Avhen  reclining,  are  able  to  voluntarily  urinate  when 
raised  to  a  sitting  posture,  probably  because  of  the  greater  facility  with 
which,  in  the  latter  case,  the  pressure  of  the  lax  abdominal  parietes  can 
be  exerted  upon  the  bladder. 

Loss  of  Weight. — Owing  to  the  rapid  retrograde  changes  in  the 
pelvic  organs,  the  discharges  from  the  genital  passage,  the  increased 
secretions  of  the  skin  and  kidneys,  combined  with  limited  ingestion  of 
food,  the  loss  of  weight  in  the  first  week  amounts  to  from  nine  to  ten 
pounds,  or,  roughly  speaking,  to  about  one  twelfth  the  weight  of  the 
body.t 

Involution. — The  processes  by  means  of  which  the  uterus  returns  to 
its  non-puerperal  condition  are  inaugurated  at  the  commencement  of 
labor.  During  the  rapidly  following  contractions  of  the  uterus  the 
cell-elements  are  consumed,  while,  at  the  same  time,  the  compression 
of  the  nutrient  vessels  cuts  off  fresh  supplies  from  the  oxidized  pro- 
toplasm. The  fatty  degeneration  of  the  muscular  fibers  continues 
after  the  expulsion  of  the  ovum.  The  contractions  which  bear  the 
name  of  after-pains  point  to  the  continuance  of  muscular  cells  capable 
for  a  time  of  functional  performance.  Gradually,  however,  the  pro- 
teine  substances  are  converted  into  fats,  which  undergo  absorption. 
Whether  the  enormously  enlarged  cells  of  pregnancy  ever  entirely  dis- 
appear is  still  an  open  question.  In  the  fourth  week  young  cells  of 
new  formation  make  their  appearance  upon  the  external  layer  of  the 
uterus,  from  which  eventually  a  new  uterus  is  developed.  Thus  de- 
struction and  reparation  go  hand  in  hand.  In  from  six  to  eight  weeks, 
the  process  described  reaches  its  completion.  The  lochia  then  cease, 
and,  in  women  who  do  not  nurse,  menstruation  returns  (Schroeder). 

Immediately  after  birth  the  uterus  weighs  upward  of  two  pounds  ; 
in  two  days  the  weight  falls  to  a  pound  and  a  half  ;  tlie  uterus  is  seven 

*  JonANNOvsKY,  "  Uobcr  den  Zuckergehalt  im  Ilarne  der  Wochncriuncn,"  "  Arch.  f. 
Gynaek.,"  Bd.  vii,  p.  448. 

f  Spiegelderg,  loc.  cit.,  p.  212. 

X  Gassner,  *'  Monatsschr,  f.  Gcburtsk.,"  Bd.  xix,  p.  47. 


THE  PHYSIOLOGY  AND  MANAGEMENT  OF  CHILDBED. 


233 


to  eiglit  inches  in  length  and  about  four  and  a  half  inches  broad  ;  the 
walls  are  from  an  inch  to  an  inch  and  a  half  in  thickness  ;  at  the  end 
of  a  week  the  uterus  weighs  a  pound,  and  is  five  to  six  and  a  half  inches 
long  ;  at  the  end  of  two  weeks  the  weight  is  three  fourths  of  a  pound, 
the  length  five  inches,  and  the  walls  hardly  a  half-inch  in  thickness. 
Of  course  the  individual  variations  from  these  averages  are  very  great.* 
In  six  weeks  the  process  usually  reaches  the  end,  though  the  uterus 
remains  ever  after  somewhat  larger  and  more  rounded  than  in  nulli- 
parae (Spiegelberg). 

Reparation  of  the  Decidua. — Vv  ith  the  expulsion  of  the  ovum  the 
outer  portion  of  the  decidua  vera  for  the  most  part  adheres  closely  to  the 
reflexa,  while  the  meshy  j^ortion,  with  the  fundi  of  the  glands,  remains 
attached  to  the  uterus.  The  adherent  portion  consists  of  empty  areolar 
spaces,  of  gland  septa,  of  lymphatic  spaces  and  blood-vessels,  while 
only  the  fundal  extremities  are  lined  with  glandular  epithelium,  f  As, 
however,  the  line  of  demarkation  rarely  takes  place  throughout  the 
entire  decidua  at  any  fixed  level,  fragments  of  the  outer,  more  com- 
pact layer  may  frequently  be  found  here  and  there  clinging  to  the  inner 
surface  of  the  residual  membrane.  I 

The  uterine  cavity  is  covered  and  in  part  filled  with  at  first  a  bloody 
and  subsequently  a  muco-sanguinolent  fluid  containing  blood  and  mu- 
cus corpuscles,  and  decidua-cells  in  various  stages  of  degeneration. 

At  the  end  of  a  week  the  mucous  membrane  measures  at  most  from 
a  half  to  three  quarters  of  a  line  in  thickness  ;  the  inner  surface  has 
become  smoother  from  the  disintegration  and  exfoliation  of  adherent 
shreds  ;  the  glands,  owing  to  diminished  size  of  the  uterus,  are  pressed 
closer  together,  and  assume  a  more  nearly  perpendicular  direction  ;  the 
gland-epithelium  extends  uj)ward  along  the  gland-walls  to  the  surface 
of  tlie  membrane  ;  the  interglandular  spaces  are  filled  with  lymphoid 
cells,  with  blood-corpuscles,  fat-granules,  and  epithelial  cells,  in  a  state 
of  fatty  degeneration.  As  the  regenerative  process  goes  on,  fine  capil- 
laries without  walls  form  in  the  interglandular  substance,  so  that  the 
latter  presents  the  appearance  of  granulation-tissue.  By  the  third  week 
these  vessels  of  new  formation  stretch  upward  to  the  surface  of  the 
mucous  membrane,  and  by  the  sixth  week  the  development  of  the  vas- 
cular network  is  complete.  In  the  second  week  the  lymphoid  cells  begin 
to  dissolve,  and  thus  the  glands  are  brought  into  near  contact  with 
one  another.  Spindle-shaped  cells  of  young  connective  tissue  are  found 
between  the  glands  in  the  second  week,  and  with  continued  connec- 

*  Burner,  "  Ueber  den  puerperalen  Uterus  "  ;  Sinclair,  "  Measurements  of  the  Uterine 
Cavity,"  "Trans,  of  the  Am.  Gynaec.  Soc.,"  vol.  iv,  p.  231. 

f  Leopold,  "  Studien  iiber  die  Uterusschleimhaut,"  etc.,  "  Arch.  f.  Gynaek.,"  Bd.  xii,  p. 
180. 

X  KtisTNER,  "Die  Losung  der  miitterlichen  Eibaute,"  "Arch.  f.  Gynaek.,"  Bd.  xiii,  p. 
422. 


234 


THE  PUERPERAL  STATE. 


tive-tissue  proliferation  the  flattened  tubules  are  drawn  upward,  and 
assume  a  perpendicular  direction.  The  epithelial  cells  at  the  mouths 
of  the  glands,  which  at  first  formed  separate  islets,  approach  one  an- 
other as  the  glands  assume  their  normal  positions,  and  by  actively 
multiplying  spread  from  the  circumference  until  they  form  a  contin- 
uous lining  to  the  wounded  surface. 

As  regards  the  principal  features,  the  changes  which  take  place  at 
the  placental  site  are  the  same  as  those  described  elsewhere  within  the 
uterine  cavity.  Immediately  after  delivery,  however,  the  surface  pos- 
sesses an  uneven  aspect,  with  elevations  where  the  septa  of  the  serotina 
had  penetrated  between  the  placental  cotyledons,  and  with  intervening 
depressions.  The  mouths  of  the  torn  vessels  are  closed  by  thrombi, 
and  large  vessels  are  irregularly  distributed  beneath  the  attached  resi- 
due of  the  mucous  membrane.  The  process  of  regeneration  at  the 
placental  site  takes  place  somewhat  more  slowly  than  elsewhere  within 
the  uterus. 

Closure  of  the  Sinuses. — By  the  eighth  month  of  pregnancy,  as  has 
been  mentioned,  a  portion  of  the  sinuses  beneath  the  placenta  are  oblit- 
erated by  the  emigration  of  giant-cells  which  cause  coagulation  of  the 
blood  circulating  through  them.  After  delivery,  the  blood  stagnates 
in  the  intact  vessels  in  such  a  way  that  at  first  the  inner  walls  are 
covered  with  fibrine,  while  the  center  contains  fresh  red  blood.  The 
Avails  then  thicken  by  proliferation  of  the  endothelium,  and  lymph- 
and  blood-corpuscles  penetrate  into  the  coagulated  layer.  Finally,  the 
thrombus  fills  the  entire  vessel,  spindle-shaped  colls  radiate  from  the 
endothelium,  and  with  the  development  of  young  connective  tissue  a 
gradual  shrinkage  takes  place,  which,  however,  proceeds  slowly,  so  that 
four  to  five  months  after  birth  the  placental  site  is  still  distinguish- 
able."^ According  to  Engelmann,  pigmentary  deposits  in  the  tissue  of 
the  mucous  membrane  are  almost  conclusive  evidence  of  recent  deliv- 
ery, as  after  menstruation  they  are  not  found,  probably  on  account 
of  the  superficial  character  of  the  haemorrhage. 

The  Cervix. — The  cervix  speedily  resumes  after  delivery  its  normal 
size.  At  first  it  has  a  soft  and  pulpy  feel.  The  os  internum  (ring  of 
Bandl)  forms  a  resistant  ring,  which  constitutes  a  well-defined  boun- 
dary between  the  corpus  and  cervix  uteri.  This  ring  varies  in  size  in 
different  subjects,  but  is  always  sufficiently  open  to  permit  the  intro- 
duction of  two  fingers.  Beneath,  the  walls  are  thrown  into  transverse 
and  longitudinal  folds.  The  os  externum  is  usually  torn,  especially 
upon  the  sides,  and  the  thickened  labia  roll  outward.    Tlie  length  of 

*  Leopold,  "  Studien  iiber  die  Uterussclilcimhaut,"  etc.,  '*  Arch.  f.  Gynack.,"  Bd.  xii, 
p.  169 ;  Engelmann,  "  The  ]\Iucous  Membrane  of  the  Uterus,"  "  Am.  Jour,  of  Obstct.," 
May,  1875  ;  Spiegelberg,  "  Lehrbuch,"  p.  214  ;  Schroeder,  "  Lchrbuch,"  p.  222  ;  Kustner, 
"Die  Losung  der  miitterlichen  Eihaute,"  etc.,  "Arch.  f.  Gynaek.,"  Bd.  xiii,  p.  422; 
Friedlander,  "  Arch.  f.  Gynack.,"  Bd.  ix,  p.  22. 


THE  PHYSIOLOGY  AND  MANAGEMENT  OF  CHILDBED. 


235 


the  canal  measures  two  and  three  quarters  inches,  and  upward.  At 
the  end  of  twelve  hours  the  distinction  between  the  cervix  and  vagi- 
na is  clearly  marked,  and  the  os  internum  is  so  far  closed  that  a  cer- 
tain amount  of  force  is  requisite  to  pass  two  fingers  into  the  uterine 
cavity.  The  contraction  of  the  os  internum  renders  the  longitudinal 
folds  more  pronounced  in  the  upper  portion  of  the  canal.  From  this 
time  on,  the  involution  of  the  cervix  advances  rapidly.  At  the  end 
of  twelve  days  the  canal  is  shortened  to  an  inch  in  length.  As  the 
longitudinal  muscles  contract,  the  plicae  palmatae  become  distinct  as 
transverse  ridges.  The  longitudinal  folds,  with  the  exception  of  the 
anterior  and  posterior  ridge  which  belong  to  the  plicae  palmatae,  dis- 
appear with  the  retrograde  changes  which  take  place  in  the  mucous 
membrane.  The  os  externum  long  remains  patulous,  and  permits  the 
finger  to  pass  to  the  os  internum  for  a  period  varying  between  the  sev- 
enth and  fourteenth  days.  The  anterior  lip  is  thicker  than  the  poste- 
rior, and  is  frequently  the  seat  of  erosions  and  granulations.  The 
involution  of  the  vaginal  portion  is  not  completed  until  after  the  ex- 
piration of  five  to  six  weeks.* 

The  Vagina. — The  vagina  during  tlie  first  few  days  is  soft,  smooth, 
and  relaxed,  and  requires  from  three  to  four  weeks  to  regain  its  nor- 
mal dimensions.  The  contraction  and  involution  proceed  more  rap- 
idly at  the  introitus  than  above  in  the  neighborhood  of  the  fornix, 
though,  o^dng  to  the  jDresence  of  lacerations,  it  remains,  with  few 
exceptions,  permanently  wider  than  in  women  who  have  never  borne 
children. 

Position  of  the  Uterus. — Immediately  after  the  expulsion  of  the 
placenta  the  contracted  uterus  is  felt  through  the  abdominal  walls  as  a 
firm,  solid  body,  of  a  flattened,  pyriform  shape.  When  both  hips  are 
on  the  same  level,  and  both  bladder  and  rectum  are  empty,  the  uterus 
is  found  in  the  median  line  with  the  fundus  between  the  symphysis 
and  the  navel.  At  the  same  time  the  weight  of  the  body  and  the 
laxity  of  the  abdominal  walls  lead  to  a  moderate  degree  of  ante- 
flexion. Urine  in  the  bladder  and  faeces  in  the  rectum  give  rise  to  a 
certain  amount  of  lateral  displacement,  and  now  and  then  to  a  torsion 
of  the  uterus  upon  its  long  axis.  As  in  pregnancy,  the  fundus  of  the 
uterus  is  thus  generally,  though  not  always,  directed  to  the  right,  and 
the  left  border  looks  to  the  front.  The  mean  elevation  of  the  fundus 
above  the  symphysis  is  about  four  atid  one  third  inches,  the  width  of  a 
the  fundus  is  upward  of  four  inches,  and  the  length  of  the  entire 
uterine  cavity,  as  measured  by  the  sound,  is  in  the  neighborhood  of  six 
inches.    The  dimensions  of  the  uterus  are  somewhat  less  in  primiparae 

*  LoTT,  "  Zur  Anatomie  und  Physiologie  der  Cervix  Uteri,"  pp.  87  et  seq.  ;  Borner, 
"  Ueber  den  piicrpcralen  Uterus,"  p.  47,  states  that  at  the  end  of  the  second  week  the 
OS  internum  permits  the  passage  of  the  finger  in  about  half  the  cases,  but  is  closed  in  all 
by  the  end  of  the  third  week. 


236 


THE  PUERPERAL  STATE. 


than  in  multiparse.  A  full  bladder  pushes  the  fundus  upward,  and 
increases  the  longitudinal  diameter  of  the  organ.  Borner  has  observed 
an  increase  from  this  cause  amounting  to  three  and  a  half  inches. 

A  diminution  in  the  size  of  the  uterus  is  apparent  in  most  cases  in 
the  course  of  the  first  twenty-four  hours.  An  actual  increase  is  either 
pathological  or  due  to  the  above-mentioned,  influence  of  the  bladder. 
The  diminution  is  most  marked  in  the  first  twenty  days,  but  after- 
ward progresses  at  a  slow  rate.  About  the  tenth  day  the  fundus  sinks 
below  the  level  of  the  symphysis  pubis,  and  the  posterior  surface  of 
the  anteflected  uterus  occupies  the  plane  of  the  brim.* 

After-Pains. — The  reduction  of  the  uterus  in  the  first  few  days  of 
the  childbed  period  is  in  the  main  the  result  of  contractions,  termed 
after-pains,  resembling  those  of  labor  both  as  regards  the  hardening 
of  the  uterine  walls  perceptible  through  the  abdominal  coverings,  and 
the  nature  of  the  dolorous  sensations  which  they  evoke.  The  after- 
pains  stretch  over  a  period  varying  from  one  to  four  days.  Their 
duration  and  intensity  are  in  inverse  proportion  to  the  duration  and 
activity  of  the  preceding  labor.  On  this  accoant  they  are  more  pro- 
nounced in  multiparae,  while  they  are  often  absent  subsequent  to  a 
first  delivery.  They  are  intimately  associated  with  the  permanent  re- 
traction of  the  uterus,  and  are  therefore  to  be  regarded  as  a  normal 
and  favorable  phenomenon.  They  are  especially  prominent  in  cases 
of  over-distention  of  the  uterus,  as,  for  instance,  in  cases  of  twin  preg- 
nancies and  hydramnios.  Suckling  the  infant  produces  reflex  contrac- 
tions of  a  somewhat  intense  character. 

The  Lochia. — The  discharges  from  the  genital  passage  consequent 
upon  delivery  are  termed  the  lochia.  At  first  the  latter  are  composed 
of  pure  blood  with  coagula  of  fibrine,  but  after  a  few  hours  the  wound- 
ed surface  of  the  uterus  furnishes  an  abundant  exudation  of  a  serous, 
alkaline  fluid,  which  washes  away  in  its  descent  the  secretion  from  the 
cervix  and  the  vaginal  mucus.  For  the  first  two  or  three  days  the 
lochia  are  of  a  red  color  {lochia  rubra)  from  the  commingling  of  blood, 
while  upon  the  third,  fourth,  and  sometimes  upon  the  fifth  day,  as  the 
sanguineous  elements  diminish,  they  present  a  pale-red  color  {lochia 
serosa).  As  constituents  we  find  under  the  microscope  cervical  and 
vaginal  epithelium,  blood  and  mucus  corpuscles,  bits  of  decidua,  and 
sometimes  shreds  of  membranes  and  of  the  placenta.  The  organic  con- 
stituents consist  of  albumen,  mucine,  the  saponified  fats,  and  a  variety 
of  saline  matters.  From  the  fifth  to  the  seventh  or  eighth  day  the  dis- 
charge continues  thin,  but  the  blood-corpuscles  become  less  abundant, 
while  there  is  an  increase  in  the  pus-cells  and  fatty  globules.    In  the 

*  Borner,  loc.  cit. ;  Crede,  "  Bcitriige  zur  Bestiinniungdcr  normalcn  Lage  dcrgesunden 
Gebarmutter,"  "Arch.  f.  Gynack.,"  Bd.  i,  1870,  p.  84;  Pfannkuch,  "  Ueber  die  Einfluss 
dcr  Nachbar-Organe  auf  die  Lage  und  Involution  dor  puerperalen  Uterus,"  "Arch.  f.  Gy- 
naek.,"  Bd.  iii,  1872,  p.  327. 


THE  PHYSIOLOGY  AND  MANAGEMENT  OF  CHILDBED.  237 


second  week  the  discharge  becomes  of  a  grayish-white  or  greenish-yel- 
low color  {lochia  alba  sen  lactea),  and  of  a  creamy  consistence.  It 
contains  chiefly  pus-corpuscles,  young  epithelial  cells,  spindle-shaped 
connective-tissue  cells,  fat-granules,  free  fat,  and  crystals  of  choles- 
terine.  The  reaction  is  neutral  or  acid.  Gradually  the  discharge 
diminishes,  becomes  transparent,  and  finally  assumes  a  normal  appear- 
ance. After  the  fourth  day  the  odor  is  recognizable,  and  the  lochia 
are  found  to  contain  bacteria,  indicative  of  decomposition.  In  the 
vaginal  secretion  the  trichomonas  vaginalis  is  likewise  present.  To- 
ward the  end  of  the  first  week,  and  especially  after  leaving  the  bed, 
fresh  blood  often  makes  its  appearance.  * 

The  quantity  of  the  lochia  varies  with  the  peculiarities  of  the  indi- 
vidual. It  is,  as  a  rule,  greater  in  multipart,  in  women  who  do  not 
nurse  their  children,  and  in  those  of  flabby  fiber,  who  habitually  men- 
struate abundantly.  The  mean  quantity,  according  to  Gassner,  of  the 
lochia  cruenta  or  rubra  (to  fourth  day)  amounts  to  nearly  two  and  a 
fourth  pounds ;  of  the  lochia  serosa  (to  sixth  day)  to  rather  more  than 
nine  ounces  ;  and  of  the  lochia  alba  (to  ninth  day)  to  six  and  two  thirds 
ounces  :  so  that  the  entire  amount  lost  during  the  first  eight  days 
reached  the  total  amount  of  nearly  three  and  a  quarter  pounds. 

The  Secretion  of  Milk. 

Anatomical  Considerations. — The  breasts,  which  furnish  the  secre- 
tion of  the  milk,  are  two  large  glands  of  the  compound  racemose  vari- 
ety. They  are  covered  by  a  fine,  supple  skin  and  a  layer  of  adipose 
tissue,  which  increases  in  thickness  toward  the  periphery  of  the  organ. 
The  mass  of  the  glandular  substance  is  composed  of  from  fifteen  to 
twenty-four  lobes,  which  in  turn  are  subdivided  into  lobules  made  up 
of  a  greater  or  less  number  of  acini,  or  culs-desac.  Fine  canaliculi 
start  from  the  latter,  and  unite  together  to  form  the  canals  of  the 
lobules.  These  again  anastomose,  to  form  a  principal  canal  for  each 
lobe,  termed  the  lactiferous  duct.  The  lactiferous  ducts  terminate  at 
the  nipple  by  small  openings  measuring  only  from  one  sixtieth  to  one 
fortieth  of  an  inch.  Each  duct,  as  it  passes  downward,  enlarges  in  the 
nipple  to  one  twenty-fifth  or  one  twelfth  of  an  inch  in  diameter,  and 
beneath  the  areola  it  presents  an  elongated  dilatation,  from  one  sixth 
to  one  third  of  an  inch  in  diameter,  called  the  sinus  of  the  duct 
(Flint).  The  spaces  between  the  lobes  are  filled  with  adipose  tissue, 
and  the  various  elements  which  constitute  the  mammary  glands  are 
united  into  a  single  mass  by  a  dense  connective  tissue  continuous  with 
that  of  the  subcutaneous  layer.  The  acini,  which  are  merely  rudimen- 
tary in  the  non-pregnant  state,  are  lined  with  a  single  layer  of  small 
polyhedral  cells,  assuming  a  more  cylindrical  character  in  the  neighbor- 

*  Vide  ScHROEDER,  "  Lehrbuch,"  etc.,  6te  Aufl.,  p.  226  ;  Spiegelberg,  "  Lehrbuch,"  p. 
218. 


238 


THE  PUERPERAL  STATE. 


hood  of  the  canalicular  ducts.  The  main  ducts  are  lined  with  low 
cylindrical  cells,  and  contain  in  their  walls  non-striated  muscular  fihers, 
the  contractions  of  which  are  the  cause  of  the  spurting  of  the  milk  in 
lactation. 


c 

Fig.  136. — Mammary  gland,  a,  nipple,  the  central  portion  of  which  is  retracted  ;  5,  areola ; 
c,  c,  c,  c,  <?,  lobules  of  the  gland :  1,  sinus,  or  dilated  portion  of  one  of  the  lactiferous 
ducts ;  2,  extremities  of  the  lactiferous  ducts,  (Liegeois.) 

During  pregnancy  the  breasts  enlarge  in  consequence  of  the  swelling 
and  increase  of  the  connective  tissue,  the  accumulation  of  fat  between 
the  lobes,  and  the  multiplication  of  the  acini,  which  fill  with  fatty  glob- 
ules resulting  from  the  disintegration  of  the  lining  epitlielial  cells. 
The  changes  in  the  secretory  apparatus  give  rise  to  irregularly  dis- 
tributed nodular  cords,  which,  however,  at  first  are  most  distinct  at 
the  periphery,  and  thence  advance  toward  the  center  of  the  organ. 
With  continued  development  a  lactescent  fluid  is  produced,  which 
either  exudes  spontaneously  from  the  nipple  or  is  discliarged  by  press- 
ure. 

Milk-Fever. — About  the  tliird  or  fourth  day  of  the  childbed  period, 
the  turgescence  of  the  breasts  is  suddenly  increased,  and  they  become 
full,  tense,  nodular,  and  sensitive  to  the  touch.  The  axillary  glands 
enlarge,  and  radiating  pains  are  experienced  in  the  arm  and  shoulder. 
The  intensity  of  the  mammary  congestion  varies  in  different  individ- 
uals. It  is  more  pronounced  in  women  who  postpone  nursing  their 
children  until  after  the  secretion  of  milk  is  fully  established.    In  ex- 


TIIE  PHYSIOLOGY  AND  MANAGEMENT  OF  CHILDBED.  239 


ceptional  cases  it  may  be  absent  altogether.  Since  the  general  intro- 
duction of  the  thermometer  into  practice,  and  the  better  understanding 
of  the  causes  of  febrile  temperatures  in  the  puerperal  state,  the  exist- 
ence of  a  distinct  milk-fever  referable  to  functional  disturbances  in 
the  breasts  during  the  period  in  question  has  been  found  to  be  an  en- 
tirely exceptional  occurrence.  The  temperature  tables,  which  have 
been  kept  with  great  regularity  for  the  past  ten  years  in  the  Maternity 
Hospital  of  this  city,  prove  that  under  normal  conditions  the  tempera- 
tures of  the  third  day  do  not  rise  above  100J°.  With  this  sub-febrile 
increase  there  is,  indeed,  often  conjoined  considerable  general  dis- 
turbance, indicated  by  slight  chilly  sensations,  headache,  anorexia, 
and  a  quickened  pulse,  which,  however,  disappear  in  the  course  of 
twenty-four  hours,  with  profuse  perspiration,  and  an  abundant  secre- 
tion of  milk.  Most  writers  regard  the  higher  temperatures  which  are 
sometimes  found  associated  with  extreme  turgescence,  tenderness,  and 
reddening  of  the  mammse,  and  which  subside  when  the  latter  are 


Fig.  137. — Section  through  acinus  from  breast  of  a  nursing  woman.  (BiHroth.) 

partially  unloaded,  as  dependent  upon  a  non-suppurative  form  of 
parenchymatous  inflammation. 

Composition  of  Milk.— Milk  is  composed  of  a  fluid  portion,  and  of 
formed  constituents,  the  first  derived  from  the  blood,  and  the  second, 
termed  the  milk-globules,  from  the  epithelial  contents  of  the  acini. 
In  the  production  of  the  milk-globules,  the  gland-cells  actively  multi- 
ply, and  become  filled  with  granular  particles,  which  gradually  coa- 
lesce to  form  drops  of  fat.  Subsequently  the  nuclei  and  the  contours 
of  the  cells  disappear,  so  that  the  latter  consist  of  mulberry-shaped 
aggregations  of  fat-drops  held  together  by  the  remains  of  the  cell-pro-  ^ 
toplasm.    The  epithelial  elements  thus  metamorphosed  are  termed 


240 


THE  PUERPERAL  STATE. 


colostrum-corpuscles.  They  are  found  sparingly  distributed  in  the 
crude,  imperfectly  formed  secretion  known  as  colostrum,  which  is  fur- 
nished by  the  breasts  of  women  who  have  been  but  recently  confined. 
Finally,  the  fat-globules  of  large  and  small  size  separate  from  one  an- 
other, and  form  an  emulsion  with  the  fluid  transuded  from  the  blood, 
a  process  aided,  according  to  Kehrer,  by  the  diffusion  through  the  fluid 
of  the  residual  protoplasm  of  the  cells.  * 

Colostrum  is  a  watery,  semi-opaque,  mucilaginous  fluid,  containing 
yellowish  streaks  composed  of  fat-globules  and  fatty-degenerated  cells 
which  hang  together  in  stringy  masses.  It  is  distinguished  from  true 
milk  not  only  in  the  physical  characteristics  mentioned,  but  in  the 
greater  proportion  of  sugar  and  inorganic  salts  it  contains,  and  in  the 
fact  that  it  coagulates  upon  boiling.  It  possesses  laxative  qualities, 
which  render  it  of  use  to  the  infant  in  aiding  the  removal  of  the  me- 
conium. 

Perfectly  formed  milk  contains  from  2*5  per  cent,  to  7*6  per  cent, 
butter  in  emulsion,  and  from  3*2  per  cent,  to  six  per  cent,  milk-sugar 
in  solution.  Both  of  these  substances  are  directly  manufactured  by 
the  gland-structures.  It  possesses  likewise  a  proteine  substance  termed 
caseine,  Avhich  fluctuates  in  quantity  between  one,  three,  and  four  per 
cent.  Kehrer  maintains  that  it  is  not  held  in  the  milk  in  solution, 
but  is  composed  of  particles  derived  from  cell-protoplasm  which  are 
diffused  through  the  fluid.  The  salts  in  the  milk  amount  to  0*14  per 
cent.f 

The  Diagnosis  of  the  Puerperal  State.— The  diagnosis  of  recent  de- 
livery is  based  uj)on  the  physiological  conditions  which,  we  have  seen, 
characterize  the  puerperal  state.  Thus,  the  abdomen  is  flabby  and 
wrinkled,  with  pigmented  linea  alba,  and  is  traversed  by  white-and-red 
lines  ;  the  breasts  are  full,  tense,  and  nodular,  and  secrete  milk  or 
colostrum  ;  the  areola  about  the  nipple  is  discolored  ;  the  uterus  is 
enlarged,  ante  flexed,  palpable  through  the  abdominal  wall,  and  is  ex- 
cited to  contract  by  pressure  ;  the  vulva  is  swollen,  the  labia  gape 
apart,  the  hymen  is  ragged,  the  perinseum  is  distensible,  and  in  recent 
cases  lacerations,  in  older  ones  ulcers  or  granulating  wounds,  are  found 
about  the  vaginal  orifice  ;  in  the  smooth,  lax  vagina  there  is  observable 
the  absence  of  the  columnse  rugarum  ;  the  cervix  is  soft,  wide  below 
and  narrowing  above,  with  the  labia  often  torn  and  contused  ;  when 
the  finger  can  be  passed  into  the  uterine  cavity,  thrombi  may  be  felt 
at  the  placental  site  ;  finally,  the  lochia  are  hardly  likely  to  be  con- 
founded with  haemorrhages  or  discharges  from  non-puerperal  causes. 

During  the  first  two  weeks  an  approximative  estimate  may  be  made 
as  to  the  date  of  confinement  by  bearing  in  mind  that  just  after  delivery 
colostrum  is  found  in  the  breasts,  the  lochia  are  bloody,  and  the  lacera- 

*  Kehrer,  "  Zur  Morphologic  des  Milch-Caseins,"  "  Arch.  f.  Gynack.,"  Bd.  ii,  p.  1. 
f  Spiegelberg,  loc.  cii.,  p.  221. 


THE  PHYSIOLOGY  AND  MANAGEMENT  OF  CHILDBED.  241 


tions  about  the  vulva  present  a  fresh  appearance  ;  that  during  the  fol- 
lowing days  the  lochial  secretion  changes  first  to  a  serous  and  then  to 
a  purulent  character  ;  that  the  uterus  gradually  diminishes  in  size, 
the  fundus  at  the  tenth  day  sinking  below  the  upper  border  of  the 
symphysis,  while  the  os  internum  remains  patulous  to  the  tenth  day, 
and  is  usually  impassable  for  the  finger  after  the  twelfth  day. 

The  New-born  Infant. 

With  the  first  inspiration  the  thorax  expands,  and  air  fills  the 
alveoli  of  the  lungs  ;  at  the  same  time  the  blood  passes  from  the  right 
side  of  the  heart  to  the  capillaries  of  the  pulmonary  organs,  and  is 
returned  arterialized  to  the  left  side  of  the  heart.  As  a  consequence 
of  the  establishment  of  the  pulmonary  circulation,  the  ductus  arteri- 
osus contracts,  the  foramen  ovale  closes,  and  the  left  ventricle  under- 
goes eccentric  hypertrophy.  As  a  consequence  of  the  diversion  of  a 
part  of  the  blood-currents  to  the  lungs,  the  pressure  in  the  aorta  sinks, 
and  the  circulation  in  that  portion  of  the  umbilical  arteries  which  lies 
outside  the  navel  ceases,  while  thoracic  aspiration  empties  the  umbili- 
cal vein.  The  cord  dries  from  the  cut  surface  toward  the  navel,  and 
drops  off  on  the  fourth  or  fifth  day.  The  line  of  demarkation  forms 
at  the  termination  of  a  capillary  network  which  extends  upward  upon 
the  cord  to  a  distance  of  from  three  to  four  lines  from  the  skin.  When 
the  cord  drops  off,  a  wounded  surface  is  left,  which  heals  in  a  few 
days. 

The  swelling  upon  the  presenting  part  subsides  mostly  in  twenty- 
four  to  forty-eight  hours.  The  head  slowly  resumes  its  normal 
shape — a  process  completed,  probably,  in  the  course  of  two  to  three 
weeks. 

Soon  after  birth  the  meconium  is  discharged  from  the  intestines, 
and  in  a  few  days  the  evacuations  assume  a  feculent  character.  The 
production  of  pepsin  in  the  stomach,  and  the  secretion  by  the  pancreas 
of  a  fluid  capable  of  emulsifying  fats  and  digesting  albuminoid  sub- 
stances, render  the  assimilation  of  milk  practicable.  The  kidneys 
excrete  an  abundance  of  urine  of  a  low  specific  gravity. 

About  the  third  day  an  exfoliation  of  the  epithelium  begins,  which 
is  maintained  for  a  week,  or  even  a  longer  .period.  During  this  time 
the  hypersemia  of  the  skin  is  very  marked,  and  imparts  to  it  a  red 
color,  which  as  it  fades  passes  into  a  yellowish  tint.  The  breasts  in 
both  sexes  swell  very  commonly,  become  red  and  sensitive,  and  yield 
upon  pressure  a  serous,  milky  fluid. 

Icterus  of  the  new-born  infant  is  a  pretty  common  affection. 
Its  occurrence  is,  however,  largely  influenced  by  local  conditions. 
Thus,  Porak  placed  the  frequency  at  eighty  per  cent,  among  the  chil- 
dren born  in  the  Ilopital  Cochin  in  Paris  ;  Kehrer,  in  the  vast  mater- 
nities of  Vienna,  at  sixty-eight  per  cent.  ;  Ebstein,  in  Prague,  at  forty- 

16 


242 


THE  PUERPERAL  STATE. 


two  per  cent.  ;  while  West  declares  it  is  a  rare  phenomenon  at  the 
Rotunda  Hospital  in  Dublin.  It  develops  usually  upon  the  second  or 
third  day,  and  ends,  as  a  rule,  by  the  sixth  to  eighth  day.  Kehrer  * 
has  shown  statistically  that  it  occurs  more  frequently  in  boys,  in  pre- 
mature infants,  in  the  children  of  primiparae,  and  as  a  consequence  of 
malpresentations.  It  is  likewise  promoted  by  atelectasis,  by  intes- 
tinal affections,  by  depressing  the  temperature  of  the  child,  by  insuf- 
ficient feeding,  and,  in  a  word,  by  all  the  various  pathological  condi- 
tions and  unfavorable  hygienic  influences  intensifying  or  giving  an 
abnormal  direction  to  the  ordinary  changes  which  take  place  in  the 
blood  (Ebstein).  Its  frequency  in  lying-in  hospitals  is  probably  con- 
nected with  a  septic  infection,  for  which  the  wounded  surface  at  the 
navel  furnishes  the  point  of  entry.  It  does  not  appear  to  be  dependent 
upon  gastro-duodenal  catarrh,  upon  a  narrowing  of  the  bile-duct,  or 
upon  retention  of  meconium.  The  faeces  are  stained  with  bile,  while 
bile-pigment  in  the  urine  is  of  exceptional  occurrence.  On  the  other 
hand,  in  all  the  tissues  of  the  body,  and  most  abundantly  in  the  kidneys, 
pigment-crystals  and  yellowish-red  amorphous  granules  are  found  de- 
posited in  greater  or  less  quantities.  These  pigment-bodies  are  presum- 
ably not  products  of  the  liver,  but  result  from  the  disintegration  of 
blood-corpuscles,  their  accumulation  in  the  organism  depending  either 
upon  the  rapidity  of  the  processes  of  destruction,  or  upon  obstructed 
elimination  by  the  kidneys.  An  expectant  treatment  is  the  only  ra- 
tional one.    Laxatives  are  unnecessary,  and  perhaps  harmful,  f 

Owing  to  the  discharge  of  meconium  and  urine,  and  the  limited 
amount  of  sustenance  at  its  disposal,  the  new-born  infant  experiences 
a  loss  of  weight  in  the  first  two  to  three  days,  estimated  at  from  seven 
to  eight  ounces.  After  the  second  or  third  day  the  loss  is  gradually 
recovered,  so  that  between  the  fifth  and  eighth  day  the  weight  at 
birth  is  reached.  The  loss  of  weight  is  greater  in  the  children  of 
primiparae  than  in  those  of  multiparae,  in  artificially  nourished  in- 
fants, and  where  the  immediate  application  of  the  ligature  to  the  cord 
at  birth  has  been  resorted  to. 

The  Managemein^t  of  the  Puerperal  State. 

Sleep. — After  every  precaution  has  been  taken  against  haemorrhage, 
after  the  patient  has  been  washed  carefully  and  placed  upon  clean,  dry 
bedding,  and  after  the  baby  has  been  bathed  and  dressed,  it  is  very  de- 
sirable that  the  mother  should  enjoy  a  few  hours  of  refreshing  sleep. 
To  this  end  the  room  should  be  darkened,  and  absolute  stillness  en- 
forced.   The  crying  of  the  baby,  the  affectionate  salutation  of  friends, 

*  Kehrer,  "Studien  iibev  den  Icterus  Neonatorum,"  "  Jahrbuch  f.  Paediatrik,"  Bd.  ii, 
p.  71,  1871. 

f  EnsTEix,  "  Ueber  die  Gelbsucht  bei  neugcborenen  Kindcrn,"  Volkmann's  "  Samml 
klin.  Vortr.,"  No.  180. 


ACCIDENTAL  COMPLICATIONS.— ABNORMALITIES  OF  THE  UTERUS.  255 


but  must  be  given  in  large  doses,  since  tlie  powers  of  digestion  and  of 
assimilation  are  seriously  impaired  by  the  puerperal  state.* 

Icterus. — Icterus,  although  a  phenomenon  of  rare  occurrence  dur- 
ing pregnancy,  is  interesting  and  important  on  account  of  its  tendency 
to  precede  or  to  accompany  the  fatal  pathological  changes  and  symp- 
tomatic events  connected  with  acute  yellow  atrophy  of  the  liver.  It 
is  ordinarily  assumed  that  this  grave  general  disease  is  developed 
from  a  form  of  icterus  wliich,  when  complicating  pregnancy,  usually 
has  etiological  relations  identical  with  those  of  simple  obstructive  or 
so-called  hepatic  jaundice,  although  the  causative  condition  frequently 
eludes  observation.  The  development  in  pregnancy  of  icterus  termi- 
nating fatally  is,  also,  sometimes  due  to  the  lesions  of  phosphorus- 
poisoning.  Davidson  f  attributes  the  fatal  influence  of  pregnancy 
upon  the  course  of  simple •  icterus  to  the  three  following  causes:  1. 
The  impairment  of  the  renal  excretory  function,  due  to  the  passive 
congestion  produced  by  uterine  pressure  upon  the  renal  veins.  This 
etiological  factor  operates  by  causing  the  retention  in  the  blood  of  the 
reabsorbed  biliary  acids,  which,  according  to  the  investigations  of 
Traube  and  others,  are  of  themselves  capable,  even  when  present  in 
the  blood  in  moderate  quantity,  of  producing  acute  yellow  atrophy. 
2.  The  hydraemia  of  pregnancy,  which  renders  the  system  less  capable 
of  resistance  to  toxic  agencies.  3.  The  impairment  of  cardiac  activ- 
ity, due  to  the  retention  of  the  biliary  acids,  which  still  further  com- 
promises renal.eliminative  action.  Icterus  often  produces  abortion  by 
destroying  the  life  of  the  foetus.  The  causative  connection  between 
icterus  and  fetal  death  has  been  proved  by  the.  intense  icterus  of  the 
dead  foetus,  by  the  detection  of  biliary  acids  in  its  blood,  and  by  the 
exclusion  of  other  causes.  Alter  abortion  a  previously  benign  icterus 
may  speedily  develop  all  the  characteristic  lesions  and  symjotoms  of 
acute  yellow  atrophy.];  Under  these  circumstances,  the  sudden  advent 
of  the  fatal  symptoms  may  be  accounted  for  by  the  anaemia  and  hy- 
drasmia  induced  by  the  haemorrhage  accompanying  parturition.  As- 
suming the  correctness  of  the  above-mentioned  deductions  with  refer- 
ence to  the  usual  etiology  of  fatal  icterus  complicating  pregnancy, 
we  must  admit  the  urgent  indication  in  these  cases  for  measures  cal- 
culated to  facilitate  the  'elimination  of  the  biliary  acids  from  the  blood 
by  restoring  the  normal  excretory  function  of  the  kidneys.  An  early 
resort  to  appropriate  measures  might,  partially  or  entirely,  prevent  the , 
accumulation  of  the  poison  upon  whose  presence  such  baneful  results 
are  believed  to  depend. 

*  Barker,  in  a  paper  termed  "Puerperal  Malarial  Fever"  ("Am.  Jour,  of  Obstet.," 
April,  1830),  furnishos  a  most  valuable  addition  to  our  knowledge  of  the  symptoms 
and  treatment  of  this  disease. 

t  Datidson,  "Monatsschr.  f,  Geburtsk,"  Bd.  xxx,  H.  vi,  1867,  p.  465. 

X  SciiROEDER,  "  L'jhrbuch  der  Geburtsh.,"  p.  366. 


256 


THE  PATHOLOGY  OF  PREGNANCY. 


Cardiac  Diseases. — The  various  effects  produced  upon  pregnancy 
by  coexisting  heart-disease  depend  entirely  upon  the  seat  and  character 
of  the  cardiac  affection.  While  the  results  of  myocarditis  are  seri- 
ous, because  of  its  interference  with  the  development  of  cardiac  hyper- 
trophy adequate  for  the  compensation  of  existing  valvular  lesions,  and 
acute  endocarditis,  occurring  during  pregnancy,  shows  a  marked  ten- 
dency to  assume  the  fatal  ulcerative  form,*  pericarditis  has  no  percep- 
tible effect  upon  the  normal  course  of  utero-gestation.f  Chronic  en- 
docarditis often  produces  disastrous  results,  which  may,  in  general 
terms,  be  accounted  for  by  the  fact  that  an  amount  of  cardiac  hyper- 
trophy completely  compensatory  for  preexisting  valvular  lesions  is  no 
longer  able  to  overcome  the  increased  arterial  and  venous  pressure 
prevailing  during  pregnancy,  or  to  adapt  itself  to  the  sudden  variations 
in  vascular  tension  due  to  the  parturient  act.  The  augmented  arterial 
pressure  which  calls  for  increased  cardiac  activity  is  referable,  in  part, 
to  the  newly  developed  utero-placental  circulation.  It  is  also  attrib- 
uted by  some  authors  to  the  actual  pressure  of  the  gravid  uterus  upon 
the  aorta ;  while  Spiegelberg  J  believes  it  to  be  measurably  due  to 
the  plethora  of  pregnancy,  and  to  the  limitation  of  the  intra-thoracic 
space  by  the  encroachments  of  the  diaphragm.  An  important  source 
of  varying  and  perturbed  heart-action  is,  moreover,  found  during  labor 
in  the  suddenly  changing  conditions  of  pressure  produced  by  the  alter- 
nating uterine  contractions  and  relaxations  with  the  corresponding 
violent  respiratory  efforts. 

Spiegelberg*  refers  the  symptoms  of  aortic  insufficiency  or  stenosis, 
which  are  usually  most  marked  in  the  later  months  of  pregnancy, 
solely  to  cardiac  disturbances  due  to  increased  arterial  tension,  and  the 
disappearance  of  these  symptoms,  after  birth,  to  the  restitution  of  the 
normal  pressure.  He  considers  the  grave  symptoms  of  mitral  disease, 
often  presenting  themselves  soon  after  confinement,  as  referable  to  ex- 
cessive distention  of  the  right  heart  with  blood  forced  into  it  from  the 
contracted  uterus.  Fritsch  ||  opposes  this  view,  and  attributes  the 
morbid  phenomena  of  mitral  disease  to  the  accumulation  of  blood  in 
the  abdominal  vessels  recently  released  from  the  pressure  of  the  gravid 
uterus,  and  to  the  cardiac  paralysis  resulting  from  an  insufficient 
blood-supply  and  consequent  defective  nutrition  of  the  heart. 

The  hydraemia  of  the  puerperal  state  may  contribute  to  the  impair- 
ment of  nutrition,  and  thus  cooperate  with  the  above  causative  agen- 
cies in  the  production  of  cardiac  paralysis. 

*  Lebert,  "  Bcitr.  zur  Casuistik  dcr  Hcrz-  und  Gefasskrankhciten  im  Pucrpcrium," 
"Arch.  f.  Gynaek.,"  Bd.  iii,  1872,  p.  39. 

f  PoRAK,  "  Dc  I'infl.  recip.  de  la  grossessc  ct  des  mal.  de  cocur,"  1880,  p.  92. 
X  Spiegelberg,  "Arch.  f.  Gynaek.,"  ii,  1871,  p.  236. 

*  Spiegelberg,  "  Uebcr  d.  Comp.  dcs  Pucrp.  m.  chron.  Horzkr.,"  ibid.,  ii,  1871,  p.  233. 
II  Fritsch,  "Die  Gcfahren  d.  Mitralisfchlcr,"  ibid.,  viii,  1875,  p.  381. 


ACCIDENTAL  COMPLICATIONS.— ABNORMALITIES  OF  THE  UTERUS.  257 


The  symptoms  of  aortic  yalvular  disease  are  usually  manifested 
during  the  latter  half  of  pregnancy.  They  consist  in  palpitations, 
dyspnoea,  and,  in  extreme  cases,  abortion  or  premature  delivery. 
Should  pregnancy  proceed  to  a  normal  termination,  the  symptoms  are 
aggravated  by  parturition,  but  disappear  speedily  after  it.  Mitral 
valvular  lesions,  if  slight  or  completely  compensated  for,  may  not 
manifest  their  existence  by  any  rational  symptoms.  If,  however,  the 
compensation  be  inadequate,  the  patient's  life  may  be  greatly  and 
sometimes  suddenly  endangered  by  the  occurrence,  either  before 
or  after  confinement,  of  extreme  pulmonary  congestion  and  oedema, 
ascites,  albuminuria  or  metrorrhagia.  The  fcBtus  may  die  in  utero, 
as  the  result  of  metrorrhagia  or  of  impaired  nutrition  due  to  defi- 
cient oxygenation  of  the  maternal  blood.  Children  whose  mothers 
are  the  victims  of  cardiac  disease  are  often  imperfectly  developed,  and 
predisposed  to  untimely  death.  The  prognosis  is  based  upon  the  gen- 
eral condition  of  the  patient.  It  is  impaired  by  coexisting  pulmonary 
lesions,  tending  to  obstruct  the  circulation  in  the  lungs,  as  well  as  by 
diseases  of  other  vital  organs.  Mitral  lesions  are  of  more  grave  signifi- 
cance than  those  at  the  aortic  orifice,  and  mitral  stenosis  is  particularly 
dangerous.  * 

Women  with  cardiac  disease  of  any  considerable  gravity  should  be 
dissuaded  from  marriage.  The  indications  for  medicinal  treatment 
are  the  same  as  for  cardiac  diseases  uncomplicated  by  pregnancy. 
Chloroform  should  be  administered  with  special  caution,  if  at  all,  dur- 
ing parturition.  The  artificial  induction  of  abortion  or  of  premature 
delivery  may  be  justified  by  the  occurrence  of  symptoms  menacing  the 
mother's  life. 

Acute  Lobar  Pneumonia. —  Pneumonia  attacks  women  less  fre- 
quently than  men.  Its  rate  of  mortality  is,  however,  much  larger 
among  the  former.  These  facts  should  be  remembered  by  investiga- 
tors of  the  reciprocal  relations  between  pneumonia  and  pregnancy,  in 
order  that  the  influence  excited  by  the  former  upon  the  latter  be 
not  exaggerated.  Pneumonia  is  an  infrequent  complication  of  the 
pregnant  state,  but  affects  the  course  of  the  latter  very  prejudicially. f 
Although  a  pneumonia  of  large  extent  may  terminate  in  complete 
recovery,  without  having  endangered  the  life  of  mother  or  foetus, |  it 
often  produces  abortion  or  premature  delivery,  the  frequency  of  these 
results  increasing  in  direct  proportion  to  the  duration  of  i)regnancy. 
The  tyi)e  of  the  pulmonary  inflammation  is  also  more  severe  in 
the  later  stages  of  utero-gestation,  and  parturition  exerts  an  unfavor- 

*  PoRAK,  op.  cit.,  p.  113 ;  Fritsch,  op.  cit.,  p.  383. 

f  Fasbender,  "  Ucbcr  P.  als  Hchwangcrsch.  Complicat.,"  etc.,  "  Bcitrag  z.  Gcburtsh.," 
iii,  1874,  Sitzgsber.,  p.  54. 

^  GussEROw,  "Pn.  b.  Scliwangercn,"  "  Mouatsschr.  f.  Geburtsk.,"  xxxii,  H.  ii,  1868 
p.  93. 

17 


S58 


THE  PATHOLOGY  OF  PREGNANCY. 


able  effect  upon  women  in  proportion  as  their  pregnancy  is  far  ad- 
vanced. * 

It  was  formerly  believed  that  pneumonia,  occurring  during  preg- 
nancy, owed  its  fatal  character  chiefly  to  the  encroachments  of  the 
graAdd  uterus  upon  the  intra- thoracic  space,  and  to  the  consequent 
interference  with  the  necessary  compensatory  increase  of  functional 
activity  on  the  part  of  the  healthy  lung-tissue.  Later  investigations 
having  not  only  shown  the  fallacy  of  this  theory, f  but  even  rendered 
probable  an  actual  increase  in  the  intra-thoracic  space  during  preg- 
nancy, |  the  fatal  character  of  intercurrent  pneumonia  is  referred  to 
coexisting  hydrsemia,  and  to  the  inability  of  the  poorly  nourished 
heart  to  restore  the  balance  of  a  pulmonary  circulation  disturbed  by 
the  consolidation  of  lung-tissue  and  by  the  consequent  impermeability 
of  large  capillary  areas.  Pulmonary  oedema,  resulting  from  progres- 
sive cardiac  asthenia,  directly  induces  the  fatal  issue.  Parturition 
itself,  whether  naturally  or  artificially  produced,  greatly  imperils  the 
v>^oman's  life  *  by  making  exorbitant  demands  upon  the  already  failing 
heart-power  and  by  aggravating  existing  hydraemia.  Abortion,  when 
occurring  under  these  circumstances,  is  referred  to  fetal  death  caused 
by  deficient  oxygenation  of  the  maternal  blood,  by  placental  anaemia 
produced  through  an  inadequate  supply  of  blood  to  the  left  heart,  and 
by  the  abnormally  elevated  maternal  temperature.  ||  From  the  fatal 
results  of  parturition  in  pneumonia  we  conclude  that  the  induction 
of  abortion  or  of  premature  delivery,  in  ordinary  cases,  is  unjustifi- 
able."^ Should  labor,  however,  have  already  begun,  its  termination 
must  be  hastened  by  all  available  means.  Our  further  treatment  must 
consist  in  efforts  at  strengthening  the  heart's  action.  Brandy  and  car- 
bonate of  ammonia,  digitalis  and  quinia,  deserve  the  most  confidence 
for  the  fulfillment  of  these  indications.  Wernich  recommends  cautious 
venesection,  for  the  relief  of  extreme  dyspnoea  or  cyanosis,  and  pro- 
poses that  the  collapse  to  which  bloodletting  may  lead  be  combated  by 
transfusion.  ^ 

Emphysema,  Chronic  Pleurisy,  and  Empyema. — These  affections  are 
dangerous  complications  of  pregnancy,  in  that  they  produce  cardiac 
dilatation,  and  prevent  the  heart  from  successfully  adapting  its  activity 
to  the  varying  conditions  of  vascular  tension  obtaining  in  parturition 
and  the  puerperal  state.  The  induction  of  abortion  or  of  premature 
delivery  may  be  indicated  by  the  existence  of  these  diseases,  provided 
the  mother's  strength  has  become  so  impaired  as  to  incapacitate  her 
for  continued  utero-gestation. 

*  Wkrnioii,  "  Beitviig.  z.  Geburtsh.,"  iii,  1874,  Sitzgsb.,  p.  56. 
f  GussEROW,  Op.  cif.,  p.  88. 

X  Wernich,  Berlin.  "Beitriig.  z.  Gcburtsli.,"  ii,  IS^S,  p.  249. 

*  Fasuender,  op.  cit.^  p.  55.  ||  Spiegelberg,  "  L^hrb.  d.  Geburtsh.,"  p.  265. 
^  Wernich,  op.  cit.,  p.  261.  ^  Sciiroeder,  "  Lchrb.  d.  Geburtsh.,"  p.  364. 


ACCIDENTAL  COMPLICATIONS.— ABNORMALITIES  OF  THE  UTERUS.  259 

Phthisis. — It  was  formerly  erroneously  held  that  pregnancy  afford- 
ed immunity  against  pulmonary  pliMsis.  This  view  may  have  been 
based  upon  the  clinical  fact  that  the  progress  of  preexistent  phthisis 
is  sometimes  retarded  by  the  supervention  of  pregnancy.*  This  re- 
sult is  observed,  according  to  Lebert^f  in  only  a  small  proportion  of 
cases.  In  the  majority  of  instances  pregnancy  not  only  hastens  the 
progress  of  actually  existing  phthisis,  but  precipitates  its  development. 
The  latter  result  is  of  especially  frequent  occurrence  in  those  heredi- 
tarily predisposed  to  the  disease,  or  in  such  persons  as  may  have  re- 
covered from  a  previous  attack.  These  effects  of  pregnancy  upon  the 
development  and  course  of  phthisis  are  most  manifest  between  the 
ages  of  twenty  and  thirty  3'ears,  although  they  are  not  infrequent  be- 
tween the  ages  of  thirty  and  forty.  The  advanced  stages  of  phthisis 
prevent  conception,  but  the  same  is  not  true  of  its  earlier  periods.  The 
puerperal  state  often  favors  the  development  of  phthisis,  particularly 
in  those  hereditarily  predisposed  to  it,  and  usually  hastens  the  fatal 
issue  of  the  disease  if  it  have  already  manifested  itself.  In  very  ex- 
ceptional instances,  however,  parturition  and  the  post-partum  state 
exert  a  favorable  influence  upon  the  course  of  phthisis.  It  often 
happens  that  women  with  inherited  tendencies  to  phthisis  may  escape 
it  during  their  first  pregnancy,  only  to  become  its  victims  in  a  later 
one. J:  Although  women  with  progressing  phthisis  may  pass  through 
the  parturient  and  puerperal  states  in  safety,  they  are  greatly  prostrated 
thereby,  and  rarely  have  sufficient  milk  to  nurse  their  children.  They, 
moreover,  often  experience  abortion  or  premature  delivery.  The  chil- 
dren of  such  women  are  usually  puny  and  feeble.  They  are  slowly 
and  imperfectly  developed  and  are  predisposed  to  pulmonary  disease. 
Prophylactic  treatment  affords  the  only  encouraging  prospects  of  suc- 
cess in  the  cases  under  consideration.  Girls  with  suspected  hereditary 
predisposition  to  phthisis  should,  accordingly,  not  marry,  as  they 
should  not  become  mothers.  If  they  do  bear  children,  they  must  never 
nurse  them. 

SjrpMlis. — When  syphilis,  which  is  a  frequent  complication  of  preg- 
nancy, is  contracted  at  the  beginning  or  during  the  course  of  the  latter, 
it  is  characterized  by  intense  initial  and  by  unusually  mild  consecutive 
symptoms.*  The  duration  of  the  incubation  is,  ordinarily,  about  two 
weeks,  but  may  be  protracted  to  six  weeks.  The  initial  lesions,  which 
are  more  extensive  than  in  women  who  are  not  pregnant,  may  involve 
the  vagina,  cervix,  labia,  nates,  and  thighs.  They  embrace  swelling, 
reddening  and  excoriation  of  the  mucous  membrane  and  skin,  oedema, 

*  Wernich,  "Berlin.  Beitrag.  z.  Geb.,"  ii,  1873,  p.  251. 

f  Lebert,  "  Ueber  Tab.d.  wciblich.  Gcschlechtsorgane,"  '*  Arch.  f.  Gynack.,"  iv,  18'72, 
p.  469.  X  SriEGELBERG,  "  Lchrb.  d.  Geburtsh.,"  p.  266. 

*  SiGMUND,  "Ucbcr  d.  Verlauf  d.  S.  bei  Schwangerschaft,"  "  Wien.  raed.  Prcsse,"  xiv, 
1873,  No.  1. 


260 


THE  PATHOLOGY  OF  PREGNANCY. 


eczema,  follicular  abscesses,  and  even  necrosis  of  connective  tissue. 
These  intense  inflammatory  processes  may  be  referred  to  increased 
nutrition  of  the  parts,  and  to  the  mechanical  results  of  friction  between 
them.  The  secondary  symptoms  are  of  a  mild  type,  consisting  chiefly 
of  general  glandular  induration,  papules  on  and  around  the  genitals, 
and  scales  on  the  palms  and  soles.  Mewis  states  that  the  occurrence 
of  parturition  has  a  favorable  effect  upon  these  lesions,  usually  result- 
ing in  their  disappearance.  Erythema,  pharyngitis,  alopecia,  iritis, 
and  febrile  movement  are  either  absent  or  slightly  marked.  Pregnant 
women  owe  the  mildness  of  their  secondary  symptoms  to  amelioration 
of  their  general  nutrition.  Syphilis  exerts  a  very  prejudicial  influence 
upon  the  product  of  conception.  If  either  parent  be  affected  with 
general  syphilis  at  the  time  of  the  coition  resulting  in  impregnation, 
syphilis  is  communicated  to  the  foetus.  It  is  almost  equally  impos- 
sible for  a  foetus  poisoned  by  the  paternal  reproductive  element  to 
infect  a  healthy  mother.  Provided  the  mother  were  untainted  at  the 
time  of  conception,  syphilis  contracted  by  her  during  pregnancy  can 
not  be  communicated  to  the  foetus.  If  the  father  be  syphilitic,  the 
infection  of  the  ovum  is  accomplished  by  the  diseased  spermatozoids. 
If  the  mother  be  constitutionally  tainted,  the  ovum  is  already  poi- 
soned. Should  both  parents  be  the  victims  of  general  syphilis,  each 
equally  bequeaths  the  disease  to  the  offspring.!  '^^^  syphilitic  poison, 
therefore,  will  not  traverse  the  septa  intervening  between  the  fetal 
and  the  maternal  vascular  systems.  |  In  rare  exceptions  to  this  general 
rule  the  mother  contracts  the  disease  by  so-called  choc  en  retour.^ 

A  progressive  and  continuous  diminution  in  the  intensity  of  fetal 
syphilis,  directly  proportionate  to  the  length  of  time  which  has  elapsed 
since  the  contraction  of  the  disease  by  the  parent  who  communicated 
it,  is  observed  in  cases  unmodified  by  treatment.  Parents  whose 
syphilis  is  allowed  to  pursue  its  natural  course  retain  the  capability 
of  transmitting  the  disease  to  their  offspring  for  varying  periods, 
the  average  length  of  which  is  ten  years.  Latency  of  the  parental 
syphilis  does  not  secure  immunity  of  the  foetus  from  the  disease, 
although  it  diminishes  the  probability  of  its  transmission.  Parents 
with  tertiary  syphilitic  symptoms  may  or  may  not  communicate  the 
disease  to  their  children,  according  as  the  poison  whose  original  pres- 
ence produced  the  gummata  is  still  retained  in  the  system,  or  has 
been  eliminated  by  nature  or  by  mercurials.  ||  In  accordance  with  the 
varying  intensity  of  the  hereditary  influence,  the  foetus  may  either 
perish  in  liter its  death  resulting  in  abortion  or  premature  delivery, 

*  Mewis,  "Sypliilis  congenita,"  "Ztschr.  f.  Geburtsh.  u.  Gynaek.,"  iv,  1879,  1,  p.  62. 
f  Kassowitz,  "  Die  Vererbung  d.  Syphilis,"  Strieker's  "  Med.  Jahrb.,"  p.  372. 
%  Kassowitz,  he.  cit.,  p.  425. 

^  Frankel,  "Ueber  Placentarsypliilis,"  "Arch.  f.  Gynaek.,"  v,  1873,  p.  44. 
I  Kassowitz,  op.  ci?.,  p.  451. 


ACCIDENTAL  COMPLICATIONS.— ABNORMALITIES  OF  THE  UTERUS.  261 


may  be  born  alive  but  destined  to  die  early,  or  may  manifest  the  dis- 
ease only  at  the  expiration  of  periods  varying  from  weeks  to  years. 
Conception  occurring  during  the  first  years  after  the  parents'  infec- 
tion v/ith  syphilis  almost  invariably  terminates  in  abortion  or  jirema- 
ture  delivery,  the  causes  of  which  are  either  the  vitiated  nutritive 
processes  of  the  foetus,  the  increased  maternal  temperature  due  to 
S3rphilitic  fever,  or  syphilitic  degeneration  of  the  fetal  placenta,  con- 
sisting, according  to  Me  wis,*  of  inflammatory  changes  in  the  tunica 
intima  of  the  blood-vessels.  Similar  pathological  changes  are  said,  by 
the  same  author,  to  occur  in  the  intima  of  the  umbilical  vessels.  The 
pathological  conditions  observed  in  syphilitic  disease  of  the  placenta 
are  either  granular  degeneration  of  the  placental  villi,  with  obliteration 
of  the  blood-vessels,  or  the  morbid  changes  designated  by  the  names 
endometritis  placentaris  gummosa  and  endometritis  decidualis.f  (For 
a  more  detailed  account  of  placental  syphilis,  vide  chapter  on  placental 
diseases. ) 

Every  pregnant  woman  who,  at  the  time  of  conception,  is  or  has 
been  affected  with  constitutional  syphilis,  should  be  promptly  subjected 
to  a  thorough  mercurial  treatment,  preferably  by  the  method  of  in- 
unction. This  is  desirable,  even  when  no  present  symptoms  are  de- 
tected, with  reference  to  the  prevention  of  the  frequently  disastrous 
influences  of  latent  syphilis.  If,  however,  the  disease  be  contracted 
during  the  later  months  of  pregnancy,  the  treatment  may  consist  of 
palliative  measures,  until  after  parturition,  since  no  harm  will  result 
from  the  maternal  syphilis  to  the  fetal  life.  Local  primary  or  sec- 
ondary disease  of  the  genitals  should  receive  appropriate  treatment,  in 
order  that  the  child  be  not  infected  during  delivery. 

Chorea  in  Pregnancy. — Chorea,  which  is  a  rare  complication  of 
pregnancy,  affects  primiparae  by  preference,  particularly  those  possess- 
ing an  hereditary  predisposition.  Barnes  X  was  able  to  collect  only  fifty- 
six  and  Fehling  *  only  twelve  additional  cases  from  the  whole  domain 
of  obstetrical  literature. 

Organic  cerebral  lesions  are  assumed  by  Spiegelberg  ||  as  estab- 
lished causes  of  the  disease.  In  regard  to  other  etiological  agencies 
wide  diversities  of  opinion  prevail.  According  to  Goodell,^  the 
choreic  movements  are  of  reflex  nature,  and  are  referable  to  im- 
paired nutrition  of  the  central  nervous  system,  incident  to  the  hydrse- 
mia  of  pregnancy.  The  association  of  chorea  and  organic  cardiac 
disease  has  been  frequently  observed,  and  the  discovery,  in  certain 
cases,  of  fibrous  vegetations  upon  the  mitral  and  aortic  valves  accounts 
for  the  assumption,  by  some  authors,  of  embolism  as  a  cause  of  chorea. 

*  Mewis,  loc.  ciL,  p.  42.  f  P'sankel,  op.  cit.,  p.  52. 
X  Barnes,  "Trans,  of  the  Ob^tet.  Soc.  of  London,"  x,  1S69,  p.  147. 

*  Fehling,  "Arch.  f.  Gynack.,"  vi,  1874,  p.  137.  ||  Spiegelderg,  "Lehrb.,"  p.  255. 
^  Goodell,  "  A;n.  Jour,  of  Obstet.,"  May,  1870,  p.  149. 


262 


THE  PATHOLOGY  OF  PREGNANCY. 


Barnes  *  discountenances  this  view,  and  calls  attention  to  the  probable 
causative  agency  of  myelitis.  Terror  and  other  intense  emotions  may 
act  as  exciting  causes  of  chorea. 

Choreic  movements  occurring  in  pregnancy  do  not  differ  from 
those  attending  the  disease  in  the  unimpregnated  state.  They  are 
usually  bilateral.  In  most  cases  the  muscular  contractions  manifest 
themselves  in  the  earlier  months  of  pregnancy,  and  continue  until 
delivery  is  accomplished.  In  rare  instances  they  are  arrested  at  the 
beginning  of  parturition.  In  still  more  exceptional  cases  the  contrac- 
tions may  either  cease  before  delivery  or  persist  during  the  post-part um 
state.  Transitory  albuminuria  and  diabetes  mellitus  are  occasional 
unexplained  complications  of  chorea  gravidarum,  and  the  phosphates 
and  urates  of  the  urine  are  present  in  abnormal  abundance.  Abortion 
and  premature  delivery,  due  to  the  repeated  succussion  of  the  uterus, 
are  of  very  frequent  occurrence. 

Chorea  exerts  a  prejudicial  influence  upon  the  course  of  preg- 
nancy, f  having  interrupted  it  in  about  one  half  the  recorded  cases. 
Death  of  the  mother  resulted  in  seventeen  of  the  fifty-six  cases 
collected  by  Barnes.  J  The  lethal  termination  was  usually  referable 
to  the  exhaustion  consequent  upon  protracted  muscular  exertion,  or  to 
hemiplegia  secondary  to  grave  cerebral  or  spinal  lesions.  The  life  of 
the  child  is  less  frequently  sacrificed,  but  it  is  itself  often  affected 
with  chorea. 

The  treatment  consists  in  the  administration  of  iron  and  quinine, 
and  the  lowering  of  the  reflex  excitability  by  the  prolonged  use  of  the 
bromide  of  potassium.  During  the  attack,  chloroform,  chloral,  and 
the  subcutaneous  injection  of  morphia  have  proved  serviceable.  When 
palliative  remedies  prove  fruitless,  in  view  of  the  perilous  nature  of  the 
affection,  artificial  labor  or  even  abortion  is  indicated. 

Surgical  Operations  during  Pregnancy. — Massot  *  concludes,  from, 
the  observation  of  a  considerable  number  of  cases,  that  ordinary  surgi- 
cal operations  do  not  interfere  with  pregnancy  unless  they  materially 
and  permanently  disturb  the  uterine  circulation,  or  call  into  activity 
the  uterine  muscular  force  by  reflex  irritation.  This  will,  most 
frequently,  be  the  result  of  operations  upon  the  external  or  inter- 
nal genital  organs.  Cohnstein  ||  states,  as  the  result  of  his  researches, 
that,  after  operations  and  injuries,  pregnancy  reaches  a  normal 
termination  in  54*5  per  cent,  of  all  cases.  Interruption  of  preg- 
nancy was,  in  his  cases,  determined  :  {a)  by  the  period  of  pregnancy 

*  Barnes,  loc.  cit,  p.  179.  f  Goodell,  "Am.  Jour,  of  Obstet.,"  vol.  viii,  p.  168. 
X  Barnes,  "  Trans,  of  the  Obstet.  Soc.  of  London,"  x,  186*.). 

*  Massot,  "  Ueber  d.  Einfluss  traumat.  Einwirk.  auf  d.  Verlauf  der  Schwangerschaft," 
Schmidt's  "  Jahrb.,"  1874,  164,  p.  266. 

I  Cohnstein,  "Ueber  chirurg.  Op.  bei  Schwangeren,"  Volkmann's  "  Samml.  klin. 
Yortr.,"  No.  59,  1873,  p.  493. 


ACCIDENTAL  COMPLICATIONS.— ABNORMALITIES  OF  THE  UTERUS.  263 

when  the  operation  took  place,  occurring  more  frequently  as  the  result 
of  surgical  measures  resorted  to  in  the  third,  fourth,  and  eighth 
months  ;  {b)  upon  the  seat  of  the  operation,  resulting  in  two  thirds 
of  all  cases,  from  operations  upon  the  genito-urinary  organs  ;  (c)  upon 
the  extent  of  the  wound,  following  amputations,  exarticulations,  and 
ovariotomies  with  great  relative  frequency  ;  (d)  upon  the  number  of 
children,  occurring  in  multiple  pregnancy  with  uniform  regularity. 
Age  seemed  to  exert  no  causative  influence.  Abortion  directly  results, 
under  these  circumstances,  from  reflex  irritation,  or  from  fetal  death 
referable  to  haemorrhage  or  to  septic  poisoning  on  the  mother's  part. 
The  prognosis,  so  far  as  the  mother  is  concerned,  depends  upon  the 
time  when  delivery  occurs.  The  mortality  ordinarily  attending  de- 
livery, if  at  term,  is  insignificant ;  for  abortions  and  premature  de- 
liveries it  amounts,  according  to  Cohnstein,  to  thirty-three  per  cent. 
The  most  frequent  causes  of  the  mother's  death  are  shock,  peritoni- 
tis, septicaemia,  haemorrhage,  and  oedema  pulmonalis.  In  view  of  the 
manifest  danger  from  operations  of  any  magnitude,  it  may  be  stated 
as  a  genera]  law  that  surgical  measures  not  absolutely  indicated  by 
the  existence  of  pathological  conditions  liable  to  aggravation  by 
delayed  interference  should  be  postponed  until  after  confinement. 
Those  morbid  conditions,  however,  whose  development  is  hastened 
by  pregnancy,  or  whose  existence  offers  mechanical  obstacles  to  par- 
turition, must  be  early  subjected  to  operative  interference.  This  re- 
mark applies  with  special  force  to  carcinomatous  growths  in  any  part 
of  the  body  and  to  intra-pelvic  tumors. 

The  time  of  operation  should  not  coincide  with  the  menstrual 
epoch  of  pregnant  women,  as  abortion  is  more  likely  to  occur  at  that 
period.*  For  a  similar  reason  it  is  recommended  that  the  third, 
fourth,  and  eighth  months  should  be  avoided.  Massot  is  of  the  opin- 
ion f  that  anaesthetics,  when  employed  during  operations  on  pregnant 
women,  exert  rather  a  favorable  than  a  prejudicial  effect  upon  fetal 
life  by  diminishing  reflex  irritation. 

Abi^ormal  Conditions  of  the  Uterus. 

Double  Uterus. — Double  uterus  occurs  under  various  forms.  The 
uterus  and  cervix  may  be  double,  the  vagina  remaining  single.  The 
double  uterus  may  have  a  single  cervix  opening  into  an  undivided 
vagina.  The  uterus,  although  double,  may  have  a  single  cervix  open- 
ing into  a  double  vagina,  the  septum  beginning  at  the  os  internum  ; 
or  uterus,  cervix,  and  vagina  may  be  double  throughout. 

All  these  forms  permit  of  normal  utero-gestation  on  either  side 
or  on  both  sides  simultaneously,  provided  that  each  half  of  the  genital 
canal  be  sufficiently  developed.    If,  however,  the  dividing  septum  ex- 

*  Spiegelberg,  "  Lohrb.  d,  Geburtsh.,"  p.  268. 
f  Massot,  loc.  ciL,  p.  26Y. 


264 


THE  PATHOLOGY  OF  PREGNANCY. 


tends  quite  to  the  vaginal  entrance,  simultaneous  pregnancy  in  each 
horn  is  exceedingly  rare.* 

If  pregnancy  occur  in  only  one  side  of  a  dou})le  uterus,  a  decidua 
vera  is  developed  in  the  other  side,  and  expelled  at  the  end  of  preg- 
nancy. Double  uterus  is  less  readily  diagnosticated  during  pregnancy 
than  after  or  before  it,  but  is  usually  recognized  with  facility.  A 
double  vagina  is  not  necessarily  indicative  of  double  uterus,  but  if 
two  vaginae  are  found,  each  containing  a  cervix,  the  presence  of  double 
uterus  may  be  safely  assumed.  If  a  double  cervix  terminate  in  an  un- 
divided vagina,  the  uterus  may  or  may  not  be  double.  When  preg- 
nancy exists  in  only  one  horn,  the  uterine  development  is  manifestly 
unilateral,  and  the  existence  of  an  unimpregnated  half  may  be  deter- 
mined by  combined  manipulation  or  by  the  uterine  sound.  In  these 
cases  presenting  a  double  uterus  with  a  single  cervix  and  vagina,  the 
diagnosis  rests  chiefly  upon  unilateral  uterine  development  and  de- 
pression of  the  fundus  and  body  corresponding  to  the  septum.  The 
form  of  a  double  uterus  is  most  plainly  manifest  during  the  contrac- 
tions accompanying  and  succeeding  parturition,  f  It  is  still  undecided 
whether  double  uterus  be  a  cause  of  abortion  and  of  premature  de- 
livery. Ordinarily,  however,  the  symptoms  and  course  of  pregnancy 
are  unaffected  by  this  malformation.  The  complete  functional  inde- 
pendence of  the  two  segments  is  demonstrated  by  the  fact  that  in 
twin  pregnancies  parturition  is  frequently  not  simultaneously  accom- 
plished by  them.  In  the  case  of  unilateral  pregnancy,  the  ratio  of 
head  to  breech  presentations  is,  according  to  Schatz,  as  twenty-one  to 
two.  Tedious  labor  may  result  in  cases  of  double  uterus,  from  uterine 
atony,  referable  either  to  imperfect  muscular  development  of  the  preg- 
nant horn,  to  its  deviation  from  the  normal  pelvic  axis,  or  to  obstruc- 
tion produced  by  the  unimpregnated  horn.  Post-partum  haemorrhage 
may  result  from  uterine  atony  or  from  attachment  of  the  placenta  to 
the  septum,  whose  imperfect  development  prevents  its  firm  and  thor- 
ough contraction. 

Anteversion  and  Anteflexion. — The  normal  ante  version  of  the  un- 
impregnated uterus  is  exaggerated  by  the  increased  weight  of  the 
gravid  uterine  body,  but  this  deviation  is  usually  rectified  by  the 
gradual  development  and  upward  movement  of  the  uterus.  In  excep- 
tional cases  the  anteversion  persists  after  the  fourth  month,  and  pro- 
duces vesical  tenesmus,  dysuria,  or  incontinence.  No  evidences  of 
uterine  incarceration  are,  however,  observed,  and  the  comparatively 
trivial  symptoms  are  relieved  by  regulating  defecation,  replacing  the 
fundus,  causing  the  patient  to  assume  the  dorsal  decubitus,  or  by  ad- 
justing an  appropriate  pessary. 

*  ScHROEDER,  "  Lchrb.  d.  Gcburtsh.,''  p.  376. 

I  Schatz,  "  Mitth.  aus  d.  Leipz.  Geb.-klinik  u.  Polyklinik,"  "  Arch.  f.  Gynaek.,"  ii, 
1S71,  p.  297. 


ACCIDENTAL  COMPLICATIONS.— ABNORMALITIES  OF  THE  UTERUS.  265 

In  the  later  stages  of  utero-gestation,  anteversion  combined  with 
anteflexion  may  again  occur,  and  produce  the  deformity  known  as 
pendulous  abdomen.  It  is,  then,  chiefly  due  to  the  inadequate  sup- 
port afforded  to  the  uterus  by  the  abdominal  parietes.  The  failure  of 
their  sustaining  power  is  referable  to  their  relaxation — which  is  most 
marked  in  multiparae — to  separation  of  the  recti  muscles,  or  to  the 
yielding  of  old  cicatrices  produced  by  operations  or  injuries.  The  dis- 
placement is  also  favored  by  lordosis  of  the  lumbar  vertebrae,  and  by 
contracted  pelvis,  which  prevent  the  normal  descent  of  the  uterus.  In 
extreme  cases  of  pendulous  abdomen,  the  uterus,  having  separated  the 
recti,  descends,  covered  by  fascia  and  skin,  almost  or  quite  to  the 
knees,  and  seriously  interferes  with  locomotion.  Its  pressure  also  pro- 
duces oedema  of  the  abdominal  wall,  vesical  tenesmus,  and  pain  in  the 
distended  cutaneous  tissues.  These  symptoms  are  relieved  by  repo- 
sition of  the  uterus,  and  by  the  application  of  a  suitable  abdominal 
bandage. 

Retroversion. — Retroversion,  a  comparatively  infrequent  form  of 
displacement  in  the  unimpregnated  uterus,  usually  rectifies  itself  dur- 
ing the  earlier  months  of  pregnancy.  Should  spontaneous  restitution 
not  occur,  the  fundus  being  detained  below  the  promontory  until  after 
the  third  month,  the  cervix  bends  upon  itself  at  an  acute  angle,  and 
the  retroversion  is  transformed  into  a  retroflexion. 

Retroflexion. — Retroflexion  occurs  infrequently  in  women  who  have 
not  borne  children,  but  often  renders  sterile  those  who  are  thus  affect- 
ed. It  is  one  of  the  most  common  uterine  displacements  in  women 
who  have  borne  children,  though  it  does  not,  in  their  case,  ordinarily 
prevent  conception.  When  conception  occurs  in  a  retroflexed  uterus, 
the  latter  usually  rises  from  the  pelvis,  and  assumes  a  position  of  ante- 
version  at  the  fourth  month.  In  many  cases,  however,  the  displace- 
ment produces  congestion  of  the  uterine  mucous  membrane,  metritis, 
and  abortion.  In  still  other  cases  the  fundus  does  not  ascend  above 
the  promontory  at  the  usual  time,  and  either  the  symptoms  of  retro- 
flexion with  incarceration  are  slowly  developed,  or  that  form  of  retro- 
flexion known  as  partial  retroflexion,  or  retroflexion  in  the  second  half 
of  pregnancy,  occurs.  This  consists  in  the  division  of  the  uterine 
cavity  into  an  anterior  and  a  posterior  diverticulum  or  pouch.  The 
anterior  diverticulum  is  produced  by  the  more  rapid  upward  develop- 
ment of  the  anterior  uterine  wall,  which  is  subjected  to  comparatively 
sligiit  pressure  and  contains  the  larger  part  of  the  foetus.  The  pos- 
terior uterine  wall  enters  predominantly  into  the  formation  of  the 
posterior  diverticulum,  and  usually  contains  the  fetal  head.  This 
peculiar  form  of  uterine  displacement  may  be  spontaneously  rectified 
during  pregnancy,  or  may  persist  until  delivery,  producing  no  impor- 
tant symptoms  except  vesical  and  rectal  tenesmus,  with  dysuria  and 
painful  defecation.    In  the  latter  case  it  materially  interferes  with  par- 


266 


THE  PATHOLOGY  OF  PREGNANCY. 


turition,  iiiasmncli  as  the  cervix,  which  is  displaced  upward  and  for- 
ward behind  the  symphysis,  is  not  situated  in  the  pelvic  axis,  and  the 
posterior  diverticulum  is  forced  by  the  uterine  contractions  against 
the  perinseum  and  posterior  vaginal  wall.  Even  at  this  stage  Nature 
may  restore  the  uterus  to  its  normal  position  ;  but,  in  default  of  spon- 
taneous restitution,  it  must  be  replaced  by  forcing  up  the  posterior 
diverticulum  with  the  hand  introduced  into  the  rectum,  while  the  an- 
terior pouch  is  displaced  downward  by  pressure  upon  the  abdomen  and 
by  traction  applied  to  the  cervix  ;  or,  where  version  is  practicable,  by 
bringing  down  the  breech,  room  may  be  made  for  the  release  of  the 
imprisoned  head. 

Retroflexion  of  the  Gravid  Uterus,  with  Incarceration— Although 
this  form  of  retroflexion  is  usually  developed  in  the  gradual  manner 
above  described,  it  may,  in  rare  instances,  be  rapidly  produced  by  sud- 
den abdominal  compression  or  concussion. 

The  symptoms,  which  are  in  either  case  essentially  the  same,  differ 
chiefly  in  the  varying  rapidity  of  their  development,  and  result  from 
the  pressure  of  the  displaced  uterus  upon  the  intra-pelvic  viscera  and 
tissues.  They  embrace  dysuria,  eventuating  sometimes  in  complete 
retention  of  urine  from  urethral  compression,  vesical  tenesmus,  incon- 
tinence of  urine,  painful  defecation,  constipation,  or  obstipation,  vio- 
lent sacral  and  lumbar  pains,  which  radiate  into  the  thighs,  and  in 
grave  cases  emesis,  with  all  the  other  symptoms  of  ileus.  Abortion, 
followed  by  spontaneous  restitution  and  recovery,  may  occur  even  at 
this  stage.  Should  incarceration,  however,  persist,  violent  metritis, 
parametritis,  and  peritonitis  may  lead  to  a  fatal  issue.  In  rare  cases, 
gangrene  of  the  uterus  or  vagina  may  be  induced.  A  lethal  termina- 
tion may  also  indirectly  result  from  pathological  processes  in  the  blad- 
der occasioned  by  retained  and  decomposing  urine.  These  morbid 
processes  consist  in  cystitis,  sometimes  complicated  by  diphtheritic  and 
gangrenous  inflammation  of  the  mucous  membrane  and  of  the  deeper 
vesical  tissues,  which  may  lead  to  septicaemia  or  to  rupture  of  the  blad- 
der. Death  may,  moreover,  result  from  passive  renal  congestion  and 
uraemia. 

The  diagnosis  of  uterine  retroflexion  with  incarceration  is  based 
upon  the  foregoing  clinical  history ;  the  fluctuating  abdominal  tumor, 
from  which  large  quantities  of  urine  may  be  obtained  by  the  catheter 
or  by  puncture ;  the  oedema  of  the  vulva ;  the  presence  in  Douglas's 
cul-de-sac  of  a  tumor  presenting  the  characteristic  consistence  of  uter- 
ine tissue ;  the  position  of  the  cervix  and  meatus  urinarius  behind  the 
symphysis  ;  and  the  distention  of  the  perinaeum  by  the  fundus  uteri. 

The  distinction  between  an  incarcerated  uterus  and  an  extra-uterine 
pregnancy  is  sometimes  difiicult,  necessitating  a  thorough  bimanual 
examination,  aided,  in  cases  of  abdominal  tenderness,  by  the  employ- 
ment of  an  anaesthetic. 


ACCIDENTAL  COMPLICATIONS.— ABNORMALITIES  OF  THE  UTERUS.  267 

The  replacement  of  the  uterus,  which,  of  course,  is  the  objective 
point  of  treatment,  should  in  all  cases  be  preceded  by  the  evacuation 
of  the  bladder.  This  is  usually  accomplished  without  much  trouble 
by  means  of  a  sharply  curved  male  catheter,  and  by  remembering  that 
the  urethra  is  ordinarily  deflected  somewhat  to  one  side.  Veit,*  in  an 
experience  of  from  seventy  to  eighty  cases,  found  catheterization 
always  practicable.  Where  intelligent  effort  is  attended  by  failure, 
puncture  is  allowable.  To  this  end  an  aspirator  needle,  which,  how- 
ever, should  not  be  of  too  small  caliber,  should  be  passed  through  the 
abdominal  walls  at  a  point  about  three  inches  above  the  symphysis. 
In  practice  this  operation  has  thus  far  proved  devoid  of  danger, 
though  the  possible  risk  from  infiltration  of  urine  should  act  as  a 
check  to  its  rash  employment. 

The  replacement  of  the  uterus  should  be  attempted  with  the  patient 
anaesthetized,  and  in  the  Sims  latero-prone  position,  f  Pressure  upon 
the  fundus  should  be  exerted  by  four  fingers  introduced  into  the  va- 
gina or  rectum.  Barnes  J  recommends  tilting  the  fundus  to  one  side, 
so  as  to  disengage  it  from  the  projection  of  the  promontory.  It  may 
happen  that  the  first  attempt  may  be  only  partially  successful,  while 
a  renewal  of  the  manipulation  after  twelve  to  twenty-four  hours  may 
lead  to  complete  reduction  (Veit).  It  is  possible  that,  after  empty- 
ing the  bladder  and  rectum,  spontaneous  reposition  may  take  place; 
but  the  expectant  plan  is  hardly  to  be  recommended,  both  because  of 
its  uncertainty  and  on  account  of  the  prolongation  of  the  patient's 
suffering. 

In  exceptional  cases  the  replacement  of  the  uterus  may  be  prevent- 
ed by  inflammatory  adhesions,  or  by  the  secondary  swelling  of  the  dis- 
placed organ.  The  induction  of  abortion  then  becomes  imperative, 
either  by  the  ordinary  methods  or  by  puncture  of  the  uterine  walls. 

The  introduction  of  a  uterine  sound  or  a  flexible  catheter  is  rarely 
practicable.  In  a  case  reported  by  P.  Miiller,*  where  the  retroversion 
was  complete,  with  the  fundus  upon  the  perinseum  and  the  cervix 
looking  directly  upward,  Miiller  resorted  to  the  following  ingenious 
expedient  :  He  cut  off  the  end  of  a  male  silver  catheter,  and  then 
bent  the  extremity  into  a  hook.  Having  succeeded  in  passing  the  lat- 
ter into  the  cervix,  he  introduced  a  piece  of  catgut  through  the  tube 
between  the  membranes  and  the  uterus.  After  twelve  hours,  during 
which  the  catgut  was  left  in  situ,  the.  foetus  Avas  expelled.  If  catheter- 
ization can  not  be  accomplished  by  either  of  the  foregoing  methods, 

*  Veit,  "  Ueber  die  Retroflexion  der  Gebai-mutter  in  den  spiiteren  Schwangerschafts- 
monaten,"  Volkmann's  "Samml.  klin.  Vortr.,"  No.  1*70,  p.  1363. 

f  If  no  anaesthetic  is  used,  the  knee-chest  position  may  be  tried  in  difficult  replace- 
ment. 

X  Barnes,  "  Obstetric  Operations,"  third  American  edition,  p.  276. 

*  P.  MuLLER,  "Zur  Therapie  der  Retrovcrsio  Uteri  gravidi,"  "  Beitr.  ziir  Geburtsh.," 
Bd.  iii,  p.  67. 


268 


THE  PATHOLOGY  OF  PREGNANCY. 


puncture  of  the  uterus  with  a  fine  trocar,  and  with  antiseptic  precau- 
tions, has  proved  a  tolerably  safe  procedure,  and,  by  the  withdrawal  of 
a  portion  of  the  amniotic  fluid,  a  certain  means  of  provoking  abortion. 

Prolapse  of  the  Pregnant  Uterus. — In  rare  instances  the  normal 
pregnant  uterus  becomes  prolapsed  during  the  early  months,  through 
mechanical  violence,  and  its  sudden  displacement  may  lead  to  abortion 
through  uterine  congestion  and  hasmorrhage.  Ordinarily,  however, 
procidentia  uteri  is  only  observed,  during  pregnancy,  when  it  has 
antedated  conception,  and  it  is  most  frequent  in  multiparas.  A  slight 
prolapse  disappears  temporarily  with  the  ascent  of  the  uterus.  A 
well-marked  procidentia,  however,  as  a  result  of  which  a  part  or  the 
whole  of  the  uterus  has  been  extruded  from  the  vagina,  is  often  at- 
tended by  symptoms  of  incarceration  terminating  in  abortion.  There 
is  no  recorded  instance  of  procidentia  in  which  pregnancy  persisted 
until  the  time  of  normal  delivery,  in  a  uterus  lying  wholly  without 
the  vagina.  Procidentia  uteri  is  simulated  by  hypertrophy,  either 
of  the  supravaginal  or  of  the  infravaginal  portion  of  the  cervix. 
This  pathological  condition  is  unattended  by  grave  results,  unless  it 
lead  to  rigidity  of  the  os  uteri,  tedious  delivery,  and  uterine  inertia. 
If  excessively  developed,  however,  the  portio  vaginalis  may  be  trans- 
formed into  a  pulpy,  polyp-like  mass,  which,  by  its  constant  friction 
and  irritation,  produces  abortion.  It  should  not  be  mistaken  for  pro- 
lapse of  the  uterus,  as  efforts  at  reposition  may  produce  irritation  suffi- 
ciently severe  to  induce  premature  delivery.  Amputation  of  the  hyper- 
trophied  cervix  may  be  performed,  during  the  third  month,  without 
disturbing  the  course  of  pregnancy,  and  is  indicated,  in  aggravated 
cases,  because  of  the  possible  prejudicial  influence  of  cervical  hyper- 
trophy, unmodified  by  treatment,  upon  utero-gestation  and  parturition. 

When  prolapse,  even  of  slight  extent,  exists  in  a  pregnant  uterus, 
the  normal  ascent  of  the  organ  should  be  encouraged  by  the  avoidance 
of  exertion,  and  by  careful  regulation  of  defecation  and  micturition. 
In  more  pronounced  cases  the  uterus  must  be  replaced  and  sustained 
by  a  suitable  tampon.  Spiegelberg  *  advises  the  use  of  a  cotton  tampon, 
soaked  in  glycerine,  and  held  in  position  by  a  perineal  bandage,  and 
renewed  at  short  intervals.  Caution  is  necessary  in  the  reduction  of 
the  uterus,  lest  the  fundus  be  caught  beneath  the  symphysis  and  the 
procidentia  converted  into  a  retroflexion.  When  incarceration  has  oc- 
curred, and  the  parts  are  much  swollen,  their  volume  may  be  reduced 
by  scarification,  after  which  reposition  must  be  attempted.  Should 
it  fail,  abortion  should  be  induced  before  the  incarceration  has  irrepa- 
rably compromised  the  vitality  of  the  pelvic  tissues. 

Prolapse  of  the  Vagina. — A  slight  degree  of  vaginal  prolapse  occurs 
more  frequently  in  pregnant  women  than  does  uterine  prolapse.  Cases 
of  more  complete  prolapse  of  the  vagina  are,  however,  almost  invari- 

*  SriKGELBEUG,  "  Gcburtsliulfe,"  p.  278. 


ACCIDENTAL  COMPLICATIONS.— ABNORMALITIES  OF  THE  UTERUS.  269 

ably  attended  with  procidentia  uteri.  The  anterior  vaginal  wall  is 
usually  alone  involved  in  the  prolapse,  although  the  posterior  wall 
may  descend  alone,  or  both  walls  become  simultaneously  prolapsed. 
This  displacement  produces  traction  upon  the  bladder  and  rectum, 
resulting  in  irritation  of  these  organs  and  of  the  vulva.  During  par- 
turition, moreover,  the  prolapsed  vagina  offers  an  impediment  to 
delivery,  and  may,  therefore,  be  subjected  to  an  amount  of  pressure  in- 
compatible with  the  maintenance  of  its  vitality.  The  treatment  con- 
sists in  producing  regular  alvine  evacuations,  and  in  sustaining  the 
vagina  with  cotton  tampons  and  a  perineal  band,  or  with  the  latter 
alone.  During  labor,  persistent  efforts  at  reposition  of  the  prolapsed 
vagina  must  be  made  between  the  pains.  Should  these  attempts  2:>rove 
effectual,  the  vagina  must  be  sustained  in  proper  position,  until  the 
descent  of  the  head  has  occurred.  If  reposition  be  impossible,  the 
forceps  must  be  resorted  to  in  order  to  prevent  the  disastrous  results 
of  excessive  pressure  on  the  vaginal  tissues,  and  traction  must  be  so 
applied  as  to  avoid  injury  of  the  anterior  vaginal  wall. 

Hernias  of  the  Pregnant  Uterus. — Although  hernias  of  the  unim- 
pregnated  uterus  are  very  rare,  they  still  occur  much  more  frequently 
than  those  of  the  gravid  uterus.  The  most  frequent  forms  under 
v/hich  they  present  themselves  are  the  umbilical  and  the  ventral. 
Femoral  and  inguinal  uterine  hernias,  as  well  as  hernias  through  the 
foramen  ovale  and  the  great  sacro-sciatic  foramen,  also  occur.  The  sac 
of  a  ventral  hernia  is  often  formed  by  the  yielding  and  dilatation  of 
extensive  cicatrices  in  the  abdominal  wall,  such  as  result  from  ovari- 
otomies and  gastrotomies,  or  by  the  separation  of  the  recti  muscles. 

Femoral  and  inguinal  uterine  hernias  are  either  congenital  or  are 
produced  by  ovarian  or  omental  hernias,  between  which  and  the  uterus 
adhesions  exist.  Pregnancy  has  been  observed  to  occur  most  frequently 
in  inguinal  uterine  hernias,  next  in  umbilical,  and  least  frequently  in 
femoral  hernias.*  It  has  never  been  discovered  in  a  uterus  which  had 
escaped  through  the  foramen  ovale  or  the  greater  sacro-sciatic  foramen. 
Pregnancy  occurring  in  inguinal  or  femoral  uterine  hernias  is  uni- 
formly terminated  by  abortion  or  by  premature  delivery.  The  diag- 
nosis is  readily  made  if  due  regard  be  paid  to  the  absence  of  the  uterus 
from  its  natural  situation,  to  the  shape  and  consistence  of  the  hernial 
tumor,  to  the  physical  signs  furnished  by  auscultation  and  i^ercussion 
over  it,  and  to  the  displacement  of  the  vagina  toward  the  site  of  the 
hernia. 

When  the  hernia  is  recognized  at  an  early  date,  the  uterus  must,  if 
l)0ssible,  be  restored  to  its  normal  position,  and  there  retained  by  an 
appropriate  truss.  Should  attempts  at  reposition  be  unsuccessful, 
artificial  abortion  should  be  induced,  as  it  will  otherwise  occur  spon- 
taneously at  a  later  date,  and  under  less  favorable  conditions.  When 

*  SriEGELBEF.G,  "  Goburtsh  ,"  p.  280. 


270 


THE  PATHOLOGY  OF  PREGNANCY. 


the  product  of  conception  has  already  attained  a  large  size^  reposition 
and  delivery,  whether  spontaneous  or  artificial,  are  rarely  accomplished 
unless  the  constricting  hernial  ring  be  previously  divided.  Even  the 
latter  procedure  may  prove  ineffectual,  in  which  case  hysterotomy  is 
the  last  resort. 


CHAPTER  XV. 

DISEASES  OF  THE  DECIDUA.-DISEASES  OF  THE  0FF3L 

Endometritis  decidua :  1.  Chronica;  2.  Tuberosa  ;  3.  Catarrhalis, — Anomalies  of  the  pla- 
centa.— Anomalies  of  form  ;  of  position ;  of  development ;  of  circulation. — Placcn- 
titis. — Degenerations. — Syphilis. — Anomalies  of  the  amnion  and  of  the  amniotic 
fluid. — Hydramnion. — Deficiency  of  amniotic  fluid. — Anomalies  of  the  umbilical 
cord;  torsion;  knots;  hernias;  coiling  of  the  cord;  cysts;  stenoses  of  vessels; 
marginal  implantations. — Hydatidiform  mole. 

Endometritis  decidua. — The  normal  congestion  of  the  uterine  mu- 
cous membrane  attendant  upon  conception,  and  resulting  in  the  forma- 
tion of  the  decidua,  may,  under  the  irritating  influence  of  various 
exciting  causes,  develop  into  endometritis.  The  inflammation  may  be 
either  acute  in  character,  as  is  often  the  case  in  cholera  Asiatica  and 
other  infectious  diseases,*  or  may  pursue  a  chronic  course,  presenting 
itself  in  the  three  distinct  forms  about  to  be  considered  : 

I.  Endometritis  decidua  chronica  diffusa. — The  causes  of  this  form 
of  endometritis  are  not  usually  readily  discoverable.  It  is  believed  to 
be  sometimes  developed  from  an  endometritis  antedating  conception. 
It  is  also  referred  to  syphilitic  infection, f  to  excessive  physical  exer- 
tion, J;  and  to  secondary  inflammation  resulting  from  the  death  of  the 
foetus  and  its  retention  in  the  uterine  cavity.* 

The  anatomical  changes  characteristic  of  this  form  of  endometritis 
consist  essentially  in  thickening  and  induration  of  the  decidua,  due 
to  a  more  or  less  diffuse  development  of  new  connective  tissue,  and  to 
proliferation  of  the  decidual  cells.  Cysts  have  been  observed  in  the 
hypertrophied  decidua  by  Hegar  and  Maier.  ||  Kaschewarowa  dis- 
covered newly  developed  and  hypertrophied  involuntary  muscular 
fibers  in  the  substance  of  the  decidua.^  Extravasations  into  the  hyper- 
trophied decidual  tissue  are  of  frequent  occurrence.^  The  decidua 
vera  or  the  decidua  reflexa  may  be  separately  or  jointly  involved  in 

*  Rlavjansky,  "  Arch.  f.  Gynaek.,"  iv,  p.  285. 
\  Frankel,  "  Arch.  f.  Gynaek.,"  v,  1873,  p.  53. 

X  Kaschewarowa,  Virchow's  "Arch.,"  1868,  vol.  xliv,  p.  113. 

*  ScHROEDER,  "  Gcburtsh.,"  sixth  edition,  p.  392. 
II  Spiegelberg,  "  Geburtsh.,"  p.  301. 

^  Kaschewarowa,  loc.  cit.,  p.  111. 

^  EiGENimoD  und  Hkgar,  "  Monatsechr.  f.  Gcburtsk.,"  vol.  xxii,  1863,  p.  161. 


DISEASES  OF  THE  DECIDUA.— DISEASES  OF  THE  OVUM.  271 


these  pathological  processes,  and  may  be  affected  throughout  a  part 
or  the  whole  of  their  extent.  When  the  hyperplasia  of  the  mucous 
membrane  is  developed  in  the  later  months  of  utero-gestation,  pursues 
a  notably  chronic  course,  is  limited  in  extent,  or  does  not  involve  the 
placental  decidua,  pregnancy  may  proceed  to  a  normal  termination. 
When,  however,  the  endometritis  appears  early,  assumes  an  acute  or 
haemorrhagic  type,  is  attended  by  partial  separation  of  the  decidua,  or 
involves  the  placental  decidua,  it  frequently  induces  abortion  or  pre- 
mature delivery,  either  by  causing  the  death  of  the  foetus  through  in- 
terference with  its  nutrition,*  or  by  exciting  reflex  uterine  contrac- 
tions. Parturition  may,  in  either  case,  be  protracted  by  the  slow 
separation  of  the  decidua,  between  which  and  the  deej)er  uterine  tis- 
sues adhesions  have  been  formed  by  the  newly  developed  connective 
tissue  and  muscular  fibers.  If  the  placental  decidua  be  involved  in 
the  morbid  process,  the  placenta  may  be  separated  with  difficulty,  and 
its  slow  expulsion  be  attended  by  copious  haemorrhages. 

11.  Endometritis  decidua  tuberosa  et  polyposa.— The  etiology  of 
this  variety  of  decidual  inflammation  is  involved  in  obscurity.  Syph- 
ihs  was  regarded  as  a  causative  agent  by  Virchow,  who  first  described 
the  degenerative  changes  under  consideration,!  and  preexistent  endo- 
metritis is  also  supposed  to  occupy  a  causative  relation  to  them.  Gus- 
serow  I  suggests  that  conception  occurring  soon  after  delivery  may 
excite  the  recently  formed  vascular  uterine  mucous  membrane  to  ab- 
normal proliferative  processes.  It  is  doubtful  whether  the  latter  are 
ever  secondary  to  irritation  produced  by  the  death  of  the  foetus.*  In 
Ahlfeld's  cases  the  inflammation  was  apparently  idiopathic. 

The  pathological  processes  peculiar  to  this  variety  of  endometritis 
are  usually  observed  in  the  decidua  vera  alone,  and  manifest  a  prefer- 
ence for  those  portions  of  the  decidua  corresponding  to  the  anterior 
and  posterior  uterine  surfaces.  In  some  cases,  characterized  by  absence 
of  the  decidua  vera,  the  decidua  reflexa  is  found  involved  in  the  mor- 
bid changes.  The  latter  consist  in  marked  thickening  of  the  entire 
decidua  referable  to  proliferation  of  the  interstitial  connective  tissue 
and  to  extensive  hypertrophy  of  the  decidual  cells,  which  are  provided 
with  nuclei  of  enormous  size.  Occasional  free  nuclei  occur.  ||  The 
uterine  surface  of  the  decidua  is  rough  and  covered  with  coagulated 
blood,  while  the  entire  mucous  membrane  is  exceedingly  vascular. 
Upon  that  surface  of  the  decidua  which  is  directed  toward  the  ovum 
are  situated  large  excrescences  or  elevations,  the  prevailing  shape  of 
which  is  polypoid.    They  may,  however,  appear  in  the  form  of  nod^ 

*  Klebs,  "Monatsschr.  f.  Geburtsk.,"  1866,  vol.  xxvii,  p.  402. 
f  AnLFELD,  "Arch.  f.  Gynaek.,"  vol.  x,  1876,  p.  173. 

■{  GcssEROW,  "Monatsschr.  f.  Gynaek.,"  vol.  xxvii,  1866,  p.  323. 

*  ScHROEDER,  "  Gcburtsh.,"  sixth  edition,  p.  393. 
II  GcssEROW,  he.  ciL,  p.  S22. 


272 


THE  PATHOLOGY  OF  PREGNANCY. 


ules,  of  cones,  or  of  boss-like  projections  provided  with  a  broad,  non- 
pedunculated  base.  Their  height  is  from  one  quarter  to  one  half  an 
inch,  and  their  surface  is  smooth,  very  vascular,  and  devoid  of  uterine 
follicles.  The  latter  are,  however,  plainly  visible  on  the  mucous  mem- 
brane intervening  between  the  polypoid  outgrowths,  but  they  are  com- 
pressed and  their  orifices  constricted  or  obliterated  by  the  pressure 
of  whitish,  contracting  bands  of  newly  developed  connective  tissue. 
Similar  fibrous  bands  surround  the  blood-vessels.  On  section,  the 
larger  prominences  sometimes  appear  permeated  with  coagulated  blood, 
and  narrow,  cord-like  bands  of  hypertrophied  decidual  tissue  occasion- 
ally form  bridge-like  connections  between  neighboring  polypi.  The 
uterine  follicles  are,  in  some  cases,  filled  with  blood-clots.  The  epi- 
thelium is  often  absent  from  the  uterine  surface  of  the  decidua  except 
around  the  orifices  of  tlie  follicular  glands,*  and  the  deeper  decidual 
tissues  contain  large  numbers  of  lymj)hoid  cells.  The  cells  of  the 
decidua  reflexa  frequently  undergo  fatty  degeneration.  The  placental 
villi  may  show  hypertrophy  of  their  club-shaped  ends,  or  be  the  seat 
of  myxomatous  growths,  in  which  case  their  cells  are  granular  and 
cloudy.  The  foetus  is  generally  dead  and  partially  disintegrated. 
This  form  of  endometritis  decidua  is,  consequently,  usually  accom- 
panied by  abortion,  which  occurs  predominantly  at  an  early  stage  of 
pregnancy. 

III.  Endometritis  decidua  catarrhalis.— Hydrorrhoea  gravidarum.— 

This  form  of  uterine  inflammation  is  less  intense  than  the  two  varie- 
ties just  described,  affects  pluriparae  more  frequently  than  primiparae, 
and  seems  to  stand  in  etiological  relations  with  hydraemia.  The 
pathological  processes  involved  in  the  disease  are  vascularity,  hyperae- 
mia,  and  hypertrophy  of  the  interstitial  connective  tissue  and  of  the 
glandular  elements  of  the  decidua.  f  The  inflammation  involves  the 
decidua  vera  by  preference,  but  may  simultaneously  affect  the  de- 
cidua reflexa.  J;  The  most  striking  symptomatic  occurrence  is  due  to 
the  glandular  hypertrophy,  and  consists  in  the  escape  from  the  uterine 
cavity  of  a  thin,  watery,  muco-purulent  or  sero-sanguinolent  liquid, 
which  resembles  the  amniotic  fluid  both  in  color  and  in  odor.  Pro- 
vided that  free  exit  be  afforded  to  the  secretion,  its  discharge  is  effected 
gradually  and  in  small  quantities.  Should,  however,  obstacles  to  its 
continuous  evacuation  be  encountered,  either  in  the  usual  adhesions 
between  the  decidua  vera  and  reflexa  or  in  impenetrability  of  the  os 
internum,  the  secretion,  having  accumulated  between  the  decidua  and 
the  chorion,  forces  a  passage  through  the  decidua  reflexa  and  is  dis- 
charged in  considerable  quantities.  In  some  cases  even  a  pound  or 
more  of  the  liquid  is  thus  suddenly  evacuated.  |    Small  quantities  of 

*  IIegau,  "  Monatsschr.  f.  Gcburtsk.,"  vol.  xxii,  1863,  pp.  300,  429. 
f  SriEGKLiJKRG,  "  Geburtsliulfo,"  p.  302. 
:):  ScHROEDKR,  "  Gcbui tsliulfc,''  p.  394. 


DISEASES  OF  THE  DECIDU A.— DISEASES  OF  THE  OVUM. 


273 


the  secretion  are  often  observed  as  early  as  the  third  month.  The 
more  abundant  discharges  occur  only  in  the  later  periods  of  pregnancy, 
and  are  often  attended  by  slight  uterine  contractions,  which  may,  in 
exceptional  cases,  become  so  severe  as  to  induce  abortion  or  premature 
delivery. 

The  diagnosis  involves  differentiation  between  a  discharge  emanat- 
ing from  the  hypertrophied  decidual  glands  and  the  ante-partum  es- 
cape of  a  fluid  which  sometimes  accumulates  between  the  amnion  and 
chorion.  The  latter  discharge,  the  quantity  of  which  may  be  so  large 
as  to  simulate  hydramnion,  differs  from  that  of  hydrorrhoea  gravida- 
rum in  that  it  occurs  only  once.*  The  escape  of  the  decidual  secretion 
might  be  mistaken  for  that  of  the  amniotic  fluid,  which  may  be  easily 
distinguished  by  the  fact  that  it  immediately  precedes  delivery.  The 
treatment  should  embrace  analeptic  and  tonic  measures  as  well  as  the 
careful  avoidance  of  vaginal  douches  and  of  all  local  irritation  tending 
to  produce  abortion.  Should  uterine  contractions  accompany  the  es- 
cape of  the  decidual  fluid,  aj^propriate  anodyne  treatment  must  be 
adopted. 

Relaxation  of  the  Pelvic  Symphyses.! — This  condition,  which  consists 
in  an  excess  of  the  ordinary  physiological  softening  at  the  pelvic  artic- 
ulations, may  permit  of  such  a  degree  of  mobility  between  the  pelvic 
bones  as  to  effectually  hinder  locomotion.  This  is  usually  accompanied 
by  pains  in  the  ligaments  of  the  joints  affected,  in  the  thighs,  and  in 
the  lumbar  region.  Its  existence  is  easily  recognized.  Thus,  motion 
at  the  symphysis  pubis  becomes  apparent  if,  with  the  patient  in  an  up- 
right position,  she  be  made  to  throw  the  weight  of  the  body  upon  each 
leg  in  alternation,  while  the  accoucheur  holds  the  symphysis  between 
the  thumb  and  two  fingers  placed  within  the  vagina.  Motion  in  the 
sacro-iliac  joint  is  perceived  by  seizing  the  crests  of  the  ilium  and  get- 
ting the  patient  to  move  forward.  In  the  recumbent  posture,  move- 
ments at  either  the  pubic  or  sacro-iliac  joints  may  be  recognized  by 
means  of  the  vaginal  touch,  upon  extending  or  flexing  the  femur. 

The  great  relief  afforded  to  all  the  symptoms  in  such  cases  by  means 
of  a  firm  binder  makes  it  most  desirable  that  the  possibility  of  its  oc- 
currence should  be  always  borne  in  mind  where  the  patient  walks  with 
difficulty  during  the  latter  months  of  pregnancy,  or  su'bsequent  to  the 
childbed  period.  The  first  case  I  witnessed  at  the  Bellevue  Hospital 
was  altogether  a  mystery  to  me,  until  the  nature  of  the  disability  was 
pointed  out  by  Professor  Barker.  The  patient  was  in  the  last  month  of 
pregnancy,  had  been  six  weeks  in  bed,  unable  to  move,  though  appar- 
ently otherwise  in  perfect  health.  A  rude  bandage,  constructed  of 
canvas  and  made  to  lace  in  front,  furnished  a  good  support,  and  ena- 

*  Spiegelreuo,  op.  cit.j  p.  303. 

f  Snelling,  "  On  Relaxation  of  the  Female  Pelvic  Symphyses,"  *'  American  Journal 
of  Obstetrics,"  February,  1870;  Barker,  "Puerperal  Diseases,"  p.  192. 
18 


274 


THE  PATHOLOGY  OF  PREGNANCY. 


bled  my  patient  to  stand  and  move  around  without  inconvenience. 
She  had,  at  the  end  of  gestation,  a  good  confinement,  and  subsequently 
recovered  without  a  trace  of  her  previous  difficulty. 

In  childbed  a  towel-binder  is  capable  of  rendering  good  service. 
During  pregnancy,  or  during  the  period  of  puerperal  convalescence, 
where  frequent  changes  of  the  bandage  are  not  necessary,  Martin's 
girdle,  consisting  of  a  solid  metal  ring  surrounding  the  whole  pelvis, 
has  been  strongly  recommended.  In  a  case  I  have  recently  had  to  treat, 
vfhere  the  relaxation  became  manifest  after  delivery,  I  employed  a  pair 
of  strong  breeches,  furnished  me  by  Philip  Schmidt,  instrument-maker, 
of  this  city,  which  were  carefully  fitted  to  the  thighs  and  hij^s  of  the 
patient,  and  were  made  to  buckle  in  front  and  lace  behind.  The  appa- 
ratus proved  to  be  light,  comfortable,  and  answered  every  requirement. 

Anomalies  of  the  Placenta. 

1.  Anomalies  of  Form. — The  usually  round  or  oval  placenta  may 
be  of  a  horseshoe  or  other  irregular  shape.  The  superficies  depends 
upon  the  extent  to  which  the  villi  form  vascular  connections  with  the 
decidua.  In  general  terms  it  may  be  stated  that  the  thickness  of  the 
placenta  is  in  inverse  proportion  to  its  surface  extension.  Placentae 
succenturiatse,  small  accessory  placental  developments,  are  due  to  the 
persistence  of  isolated  villous  groups,  which  form  vascular  connec- 
tions with  the  decidua  vera.  Placentae  spuriae  consist  of  circum- 
scribed developments  of  villi,  the  decidua  not  participating  in  the 
growth.  A  placenta  membranacea  is  a  broad  and  thin  vascular  mem- 
brane produced  by  a  diffuse  proliferation  of  the  villi  over  the  entire 
ovum,  forming  vascular  connections  with  the  reflexa  or,  where  the 
latter  is  absent,  with  the  vera. 

2.  Anomalies  of  Position.  —  The  placenta  may  be  attached  over 
the  OS  internum,  thus  constituting  placenta  praevia,  over  the  orifice  of 
the  Fallopian  tube,  or,  in  connection  with  extra-uterine  pregnancy,  at. 
various  points  in  the  abdominal  cavity. 

3.  Anomalies  of  Development. — An  hypertrophied  placenta  is  ab- 
normally large  in  proportion  to  the  size  of  the  foetus,  occurs  chiefly 
in  connection  with  hydramnion,  and  consists  of  a  genuine  2)arenchy- 
matous  hyperplasia.  A  small  placenta  is  referable  either  to  defective 
development,  to  premature  involution,  or  to  hyperplasia  of  its  connec- 
tive tissue,  with  subsequent  contraction.* 

4.  Anomalies  of  Circulation.  —  Haemorrhage  into  the  placenta  is 
sometimes  ])roduccd  by  congestion  of  the  utero-placental  vessels,  due 
to  disturbances  in  the  mother's  vascular  system,  f  The  extravasation 
may,  rarely,  be  intra-placental,  may  occur  into  the  serotina,  thus  con- 
stituting utero-placental  apoplexy,  or  may  take  place  into  the  uterine 

*  WiiiTTAKKR,  "Am.  Jour,  of  Obstet.,"  August,  1870,  p.  229. 

f  "Nouv.  Diet,  dc  Med.  et  de  Chirurg.  Prat.,"  vol.  xxviii,  "  Plaecnta,"  p.  63. 


DISEASES  OF  THE  DECIDUA.— DISEASES  OF  THE  OVUM. 


275 


sinuses.  In  the  last  case,  thrombosis  of  the  placental  sinuses  is  said 
'to  have  occurred.*  Placental  haematomata  are  the  above-mentioned 
collections  of  coagulated  blood  in  various  stages  of  disintegration. 
The  causes  of  the  haemorrhage  are,  chiefly,  morbid  changes  in  the  de- 
cidual vessels,  often  referable  to  placentitis.  The  extravasated  blood 
usually  experiences  the  ordinary  retrogressive  metamorphoses.  It 
sometimes  undergoes  cystic,  fatty,  or  calcareous  degeneration.  The 
pressure  upon  the  villi  produced  by  the  haematomata  impairs  the 
nutrition  of  the  fcetus,  and  may  cause  the  death  of  the  latter. 

(Edema  of  the  placenta,  a  morbid  condition  usually  attributed  to 
derangement  of  the  fetal  or  umbilical  circulation,  is  characterized  by 
abnormal  pallor,  with  increased  size,  friability,  and  succulence  of  the 
placenta,  due  to  serous  infiltration.  The  morbid  anatomical  changes 
consist  essentially  in  cystic  dilatation  in  and  between  the  villi,  ac- 
companied sometimes  by  extravasations. 

5.  Placentitis. — The  subject  of  placental  inflammation  is  still  in- 
volved in  obscurity.  Many  authors  dispute  its  very  existence,  con- 
tending that  the  morbid  changes  hitherto  referred  to  placentitis  are 
simply  due  to  retrogressive  metamorphoses  in  extravasations. f  Other 
writers  affirm  its  existence,  assign  to  it  etiological  relations  with  me- 
tritis and  endometritis,]:  and  describe  its  pathology  under  the  fol- 
lowing heads  :  (a)  Congestion ;  {b)  Hepatization  and  induration  ; 
(c)  Suppuration.*  According  to  the  latter  view,  the  inflammation 
originates  in  the  cells  of  the  serotina  or  in  the  adventitia  of  the  fetal 
arteries,  and  results  generally  in  the  formation  of  new  granulation 
tissue,  either  nodular  or  diffuse,  which,  by  contractions,  leads  to  com- 
pression or  obliteration  of  placental  vessels  and  to  consequent  fatty 
degeneration  of  the  villi.  Haemorrhages  also  occur  upon  the  fetal 
placental  surface,  and  fibrous  adhesions,  forming  between  the  de- 
cidua  and  the  uterine  wall,  may  lead  to  the  retention  of  the  placenta 
after  delivery.  Should  the  inflammatory  process  be  of  recent  date, 
the  friability  of  the  new  granulation  tissue  may  cause  separation  and 
retention  within  the  uterus  of  small  parts  of  the  placenta.  The 
haemorrhages  sometimes  attending  placentitis  may  destroy  the  foetus 
and  induce  abortion.  Suppuration,  circumscribed  or  diffuse,  is  a  rare 
result  of  placentitis. 

6.  Degenerations  and  New  Formations.— («)  Fatty  degeneration 
of  the  placenta,  circumscribed  or  diffused,  may  result  from  retrograde 
changes  in  extravasations.  When  developed  early  in  pregnancy,  it  is 
sometimes  regarded  as  a  premature  completion  of  the  fatty  degenera- 
tion normally  occurring  at  the  end  of  pregnancy,  and  may  be  due  to 

*  Slavjansky,  "Arch.  f.  Gynack.,"  v,  1873,  p.  360. 
f  Whittaker,  he.  cit,  p.  240. 

X  ScHROEDER,  "  Gcburtsh.,"  6te  Aufl.,  1880. 

*  "  Nouv.  Diet,  de  Med.  et  de  Chir.,"  loc.  cit.,  p.  61. 


276 


THE  PATHOLOGY  OF  PREGNANCY. 


syphilis  or  scrofula,  (b)  Amorphous  calcareous  deposits  are  frequent, 
and  are  almost  invariably  found  on  the  uterine  placental  surface,  in 
the  decidua  serotina.  Thence  the  process  may  extend  to  the  fetal 
portion  of  the  placenta.  When  the  calcareous  change  begins  in  the 
fetal  tissues  it  is  confined  to  these,  and  affects  the  small  blood-vessels 
of  the  villi,  beginning  in  their  terminal  ramifications  and  gradual- 
ly involving  their  trunks,  (c)  Pigment  deposits,  resulting  usually 
from  alterations'  in  the  hsemoglobine  of  extravasations,  are  found  in 
both  healthy  and  diseased  placentae  within  the  blood-sinuses  or  villi. 
(d)  Cysts  are  of  frequent  occurrence  in  the  placenta.  They  are  found 
near  the  center  of  its  concave  surface,  and  vary  from  a  few  lines  to 
several  inches  in  diameter.  The  cyst-wall  is  formed  by  the  protruding 
surface  of  the  amnion,  which  is  covered  with  pavement-epithelium. 
The  cysts  contain  a  reddish,  cloudy,  thin  fluid.  Ahlfeld*  regards  the 
cysts  as  liquefied  myxomatous  formations.  They  may  also  develop 
from  apoplectic  foci,  (e)  Tumors.  Circumscribed  tumors,  fibromatous 
or  sarcomatous  in  nature,!  are  found  on  the  fetal  side  of  the  placenta, 
beneath  the  amnion.  They  are  produced  either  by  fibroid  transforma- 
tions in  the  villi,  or  by  cell  proliferation  in  the  decidua.  Myxoma  of 
the  placenta,  consisting  in  hyperplasia  of  the  villi,  and  myxoma  fibro- 
sum  placentae,  characterized  by  the  fibroid  degeneration  of  the  base- 
ment-tissue in  isolated  villi,  are  the  chief  remaining  varieties  of  pla- 
cental neoplasms. 

7.  Syphilis  of  the  Placenta. — Placental  syphilis,  which  only  exists, 
according  to  Frankel,J;  in  connection  with  congenital  or  hereditary 
fetal  syphilis,  involves  the  maternal  portion  of  the  placenta,  when  the 
mother  was  infected  either  before  or  soon  after  conception,  and  pro- 
duces gummatous  proliferation  of  the  decidua,  characterized  by  the  de- 
velopment of  large-celled  connective  tissue,  with  occasional  accumula- 
tions of  younger  cells. 

When  the  infection  is  conveyed  by  the  father  to  the  foetus  alone, 
or  to  both  mother  and  foetus,  pathological  changes  occur  as  the  result 
of  a  chronic  inflammatory  process,  embracing  proliferation  of  the  cells 
and  connective  tissue  in  the  villi,  with  subsequent  obliteration  of  the 
vessels,  often  complicated  by  the  marked  proliferation  and  hardening 
of  their  epithelial  covering. 

The  affected  villi  become  swollen,  cloudy,  and  thickened,  while 
their  epithelium  undergoes  proliferation  and  cloudy  swelling.  The 
parenchyma  of  the  villi  is  filled  with  lymph-cells,  and  the  vessels  are 
either  compressed  or  obliterated.  The  blood-sinuses  are  gradually 
encroached  upon  by  the  villi,  the  foetus  dies  from  lack  of  adequate 
nutrition,  and  the  villi  undergo  fatty  degeneration.    Portions  of  the 

*  AiiLFELD,  "  Arch,  f,  Gynaek.,"  vol.  xi,  p.  397. 

f  Spiegklberg,  op.  eit.,  p.  345. 

i  Frankel,  "Arch.  f.  Gynack.,"  v,  1873,  p.  52. 


DISEASES  OF  THE  DECIDUA.— DISEASES  OF  THE  OVUM.  277 


healthy  placental  tissue,  which  often  intervene  between  the  diseased 
parts,  may  be  the  seat  of  extravasations. 

ANOMALIES  OF  THE  AmNIOIs   A^TD  OF  THE  AMNIOTIC  FlUID. 

I.  Hydramnion. — Inasmuch  as  the  amount  of  the  liquor  amnii 
varies  considerably  within  normal  limits,  the  term  h3^dramnion  should 
be  restricted  to  those  cases  in  which  the  amount  of  fluid  is  so  large  as 
to  produce  morbid  symptoms  by  its  pressure  upon  the  uterus,  the  ab- 
dominal and  thoracic  viscera,  or  the  foetus. 

Etiology. — The  causes  of  hydramnion  embrace  varied  morbid  con- 
ditions, affecting  either  the  mother  or  the  foetus.  Multi23ar8e  are  more 
predisposed  to  it  than  primiparae.  It  is  a  noteworthy  fact  that  the 
foetuses  are  females  in  the  large  majority  of  the  cases.  Schroeder  as- 
serts* that  McClintock  collected  thirty-three  cases,  in  only  eight  of 
which  the  foetuses  were  males.  The  occasional  causative  connection 
between  morbid  maternal  states  and  hydramnion  is  proved  by  the  fact 
that  the  foetus  is  sometimes  free  from  disease  while  the  mother  is 
affected  with  syphilis.  The  existence  of  lymph-channels  between  the 
amniotic  cavity  and  the  uterine  mucous  membrane  furnishes  further 
grounds  for  the  assumption  that  maternal  disease  may  induce  hydram- 
nion. t  In  most  cases,  however,  it  results  from  morbid  states  of  the 
foetus,  and  particularly  from  mechanical  disturbances  of  the  placental 
or  umbilical  circulation.  Kiistner  I  relates  a  case  in  which  hydram- 
nion was  produced  by  obstruction  in  the  umbilical  vein,  resulting 
from  hepatic  disease.  The  pathological  placental  process,  leading  to 
obstructed  umbilical  circulation,  consists  often  in  hypertrophy,  the 
villi  of  the  chorion  being  thickened  and  oedematous.  The  decidual  tis- 
sues are  sometimes  the  seat  of  inflammatory  proliferative  changes.  The 
result  of  these  diseased  conditions  of  the  membranes  is  an  abnormally 
large  secretion  of  liquor  amnii,  with  diversion  of  an  undue  share  of 
the  nutritive  material  destined  for  the  foetus,  and  the  consequent  atro- 
phy or  death  of  the  latter. 

Sjrmptoms  and  Signs. — The  distention  of  the  uterus,  and  the  conse- 
quent abnormal  expansion  of  the  abdomen,  produced  by  hydramnion, 
results  in  an  impediment  to  locomotion,  and  produces  discomfort  or 
actual  pain  by  traction  upon  the  abdominal  parietes.  The  diaphragm 
is  forced  upward,  and,  encroaching  upon  the  thoracic  space,  compresses 
the  lungs  and  displaces  the  heart,  thus  producing  dyspnoea  and  car- 
diac palpitation.  The  urine  may  become  scanty  and  albuminous  from 
impeded  renal  circulation.  Neuralgic  pains  and  oedema  of  the  labia 
and  lower  extremities  are  produced  by  compression  of  the  pelvic  nerves 
and  vessels.    Dyspeptic  symptoms  result  from  direct  compression  of 

*  Schroeder,  "  Lehrbuch,"  6te  Aufl.,  1880,  p.  437. 

f  Spiegelberg,  "  Lehrbuch,"  p.  439. 

i  KiisTNER,  "  Arch.  f.  Gynaek.,"  Bd.  x,  181&,  p.  134. 


278 


THE  PATHOLOGY  OF  PREGNANCY. 


the  digestive  organs  or  from  reflex  irritation  of  them.  Ascites  may 
be  produced  by  obstruction  of  the  portal  circulation.  Physical  exam- 
ination reveals,  in  advanced  cases,  an  immensely  distended  abdomen. 
The  uterus,  which  can  be  easily  maj^ped  out  by  palpation  and  percus- 
sion, is  tense,  elastic,  and  obscurely  fluctuating.  The  fetal  cardiac 
sounds  are  faint  or  imperceptible.  The  foetus  changes  its  position 
with  unusual  rapidity  and  facility.  Combined  manipulation  shows 
the  lower  segment  of  the  uterus  to  be  elastic  and  tense,  while  the 
foetus  can  not  be  readily  felt  by  the  finger  placed  in  contact  with  the 
cervix.  Pregnancy  accompanied  by  hydramnion  seldom  reaches  its 
normal  termination,  delivery  being  prematurely  induced  by  death  of 
the  foetus,  by  separation  of  the  placenta,  or  by  over-distention  of  the 
uterus.  The  first  stage  of  labor  is  abnormally  prolonged,  because  of 
the  comparatively  feeble  contractions  of  the  expanded  uterine  walls. 
Labor  may  become  precipitate  in  the  second  stage,  owing  to  the  sud- 
den escape  of  the  amniotic  fluid  ;  and  uterine  inertia,  in  the  third 
stage,  frequently  results  in  post-partum  haemorrhage.  Involution  is 
apt  to  be  protracted  and  incomplete. 

Diagnosis. — Hydramnion  may  be  mistaken  for  twin  pregnancy, 
but  is  easily  excluded  by  the  rational  symptoms,  by  the  tenseness  of 
the  uterine  walls,  by  the  feebleness  or  absence  of  fetal  heart-sounds, 
and  by  the  difficulty  experienced  in  perceiving  the  fetus  on  palpation. 

Prognosis. — The  prognosis  for  the  child  is  fatal  in  nearly  thirty 
per  cent,  of  the  cases.  For  the  mother  it  is  favorable,  although  the 
risk  oi  post-partum  haemorrhage  is  considerable. 

Treatment. — The  treatment  embraces  the  application  of  an  abdom- 
inal supporter  and  the  injunction  to  refrain  from  active  physical  ex- 
ertion. Grave  disturbances  of  the  mother's  heart  indicate  the  induc- 
tion of  premature  delivery,  which  should,  however,  in  the  interest  of 
the  child,  be  delayed  as  long  as  is  consistent  with  maternal  safety.  In 
parturition,  the  membranes  should  be  punctured  if  the  accumulated 
liquor  amnii  retard  the  dilatation  of  the  cervix.  Puncture  must  be 
performed  in  the  interval  of  the  pains,  in  order  that  the  waters  may 
escape  gradually  and  leave  the  position  of  the  child  unchanged.  After 
the  expulsion  of  the  placenta,  the  usual  prophylactic  measures  against 
post-partum  haemorrhage  must  be  promptly  adopted. 

II.  Abnormally  Small  Amount  of  Amniotic  Fluid. — The  quantity 
of  amniotic  fluid  may,  even  in  some  cases  of  advanced  pregnancy,  be 
so  limited  as  to  render  the  uterus  unusually  small  and  firm,  and  to 
limit  the  freedom  of  the  fetal  movements.  Under  these  circum- 
stances, the  movements  are  so  plainly  perceptible  to  the  mother  as  to 
be  the  source  of  positive  discomfort. 

An  abnormally  small  quantity  of  liquor  amnii  is,  however,  only  of 
importance  in  the  earlier  stages  of  fetal  development.  If  the  amnion 
bo  not  then  separated  from  the  foetus  by  an  adequate  amount  of  fluid, 


DISEASES  OF  THE  DEGIDUA.— DISEASES  OF  THE  OVUM.  279 


abnormal  amniotic  foldings  and  adhesions  between  the  amnion  and 
the  surface  of  the  foetus  may  take  place. 

The  so-called  foeto-amniotic  bands  *  thus  formed  may,  by  mechani- 
cal compression,  result  in  various  fetal  deformities,  or  in  spontaneous, 
intra-uterine  amputation. 

Anomalies  of  the  Umbilical  Cokd. 

I.  Torsion. — Torsion  consists  in  such  a  rotation  of  the  umbilical 
cord  upon  its  longitudinal  axis  that  its  vessels  are  thereby  rendered 
nearly  or  quite  impermeable.  It  occurs  most  frequently  in  foetuses 
which  have  advanced  beyond  the  middle  period  of  normal  utero-gesta- 
tion,  particularly,  according  to  Spiegelberg,  f  in  those  of  the  seventh 
month.  It  is,  however,  often  met  with  in  foetuses  of  an  earlier  age. 
Until  a  comparatively  recent  period,  authors  have  unreservedly  attrib- 
uted torsion  to  active  movements  on  the  part  of  the  foetus,  and  re- 
garded it  as  the  cause  of  the  latter's  death.  Martin  I  has  shown  that 
this  theory  is  untenable  for  the  majority  of  cases,  because  the  patho- 
logical conditions  which  result  from  fetal  death  induced  by  torsion, 
whether  rapidly  or  slowly  produced,  are  almost  invariably  absent. 
These  morbid  anatomical  processes  embrace  rupture  of  the  umbilical 
blood-vessels,  and  extravasations,  for  cases  of  sudden  origin,  and  con- 
gestion, with  oedema,  for  those  more  gradually  developed.  Martin, 
therefore,  concluded  that  torsion  was  a  post-mortem  event,  resulting 
from  rotation  of  the  foetus  produced  by  maternal  movements.  Ruge  * 
earnestly  advocated  the  same  view,  and  suggested  the  various  morbid 
changes  due  to  syphilis,  endometritis  placentaris,  and  sub-placental 
haemorrhage  as  the  cause  of  fetal  death  in  cases  which  subsequently 
developed  numerous  torsions.  Schauta  ||  appears  as  a  recent  champion 
of  the  same  theory,  although  he  admits  that  loose  torsions,  incapable 
of  producing  actual  stenosis  of  the  umbilical  vessels,  may  often  occur 
during  the  life  of  the  foetus.  He  bases  his  belief  in  the  post-mortem 
occurrence  of  torsion — 1.  Upon  the  large  number  of  twists  often  pre- 
senting themselves,  any  one  of  which  would  have  involved  the  death 
of  the  foetus.  Even  granting  the  original  torsion  to  have  been  of  ante- 
mortem  origin,  the  others  must  then  have  occurred  after  death.  2. 
Upon  the  improbability  of  the  formation  of  very  numerous  torsions  in 
a  healthy  cord,  inasmuch  as  its  elasticity  would  lead  to  compensatory 
reverse  rotation.  3.  Upon  the  fact  that  even  twenty -five  artificially 
induced  torsions  resulted  in  rupture  of  the  normal  cord  from  excessive 
tension.    Schauta  regards  the  cysts  found  in  connection  with  some 

*  FuRST,  "Arch.  f.  Gynaek.,"  Bd.  ii,  ISYl,  p.  318. 
f  Spiegelherg,  "  Lehrbueh,"  p.  350. 

X  Martin,  "  Ztschr.  f.  Geburtsh.  u.  Gynaek.,"  Bd.  ii,  Heft  2,  1878,  p.  346. 

*  RuGE,  ibid.,  Bd.  iii,  Heft  2,  1878,  p.  417. 

I  Schauta,  "  Arch.  f.  Gynaek.,"  Bd.  xvii,  Heft  1,  1881,  p.  20. 


280 


THE  PATHOLOGY  OF  PREGNANCY. 


torsions  as  insufficient  proof  of  their  ante-mortem  occurrence.  Tor- 
sions are  more  frequently  present  in  the  umbilical  cords  of  male  than 
in  those  of  female  foetuses,  and  are  sometimes  surprisingly  numerous. 
Schauta  reports  a  case  in  which  he  observed  three  hundred  and  eighty 
rotations  of  the  cord  on  its  longitudinal  axis.  It  occurs  by  preference 
in  multiparse,  probably  on  account  of  the  greater  latitude  afforded  for 
fetal  movements.  Unusual  length  of  the  cord  favors  its  occurrence, 
for  a  similar  reason.  The  seat  of  the  torsion  is  ordinarily  in  close 
proximity  to  the  umbilicus.  It  occurs  but  rarely  at  the  placental  end 
or  in  the  center  of  the  cord.  The  umbilical  vessels  are  usually  nearly 
occluded  at  the  seat  of  the  torsion,  but  still  permeable.  Thrombi  of 
varying  consistency  are  often  found  in  the  vessels.  Sero-sanguinolent 
fluid  in  the  abdominal  cavity  of  the  foetus,  oedema,  and  cystic  degen- 
eration of  the  cord,  are  also  pathological  conditions  frequently  attend- 
ing torsion. 

II.  Knots. — Knots  in  the  umbilical  cord,  which  occur  once  in  two 
hundred  cases,  may  result  from  the  passage  of  the  foetus  through  a 
twisted  loop  of  the  cord,  whether  the  passage  be  effected  during  preg- 
nancy, by  the  spontaneous  fetal  movements,  or  at  term,  by  the  uter- 
ine expulsive  efforts  or  by  the  manipulations  of  the  accoucheur.  Knots 
formed  during  parturition  are  loose  and  easily  untied.  They  are  un- 
attended by  any  diminution  in  the  gelatine  of  Wharton.  Those  oc- 
curring during  pregnancy  are  more  close- 
ly and  firmly  drawn,  and  more  difficult 
to  loosen,  than  the  former  variety.  The 
cord  is  partly  or  completely  denuded  of 
the  gelatine  at  the  seat  of  the  knot, 
and  plainly  shows  the  location  of  the 
latter,  after  its  solution,  by  well-marked 
indentations.  Knots  in  the  cord,  of 
either  variety,  are  comparatively  insig- 
nificant, although  a  tightly  contracted 

Fig.  i38.-Knot  of  umbilical  cord,   o^c,  in  a  thin  cord,  may  occasion  grave 
(Leyman.)  or  even  fatal  disturbance  of  the  umbili- 

cal circulation. 

III.  Hernia. — Hernia  of  the  umbilical  cord  consists  in  the  escape 
from  the  abdomen,  at  the  point  of  insertion  of  the  cord,  of  some  or  all 
of  the  fetal  abdominal  viscera.  It  is  due  either  to  arrested  embryonic 
development,  which  prevents  the  complete  closure  of  the  abdominal 
cavity,  or  to  the  failure  of  the  fetal  intestines,  originally  situated  out- 
side the  abdomen,  to  enter  the  same.  Hernia  of  the  cord  may  occur 
alone,  in  otherwise  normally  developed  foetuses,  but  is  usually  accom- 
panied by  other  deformities,  such  as  stricture  of  the  rectum,  imper- 
forate anus,  or  distortions  of  the  lower  limbs  and  of  the  genitals,  pro- 
duced by  traction  of  the  displaced  viscera  upon  adjoining  parts.  The 


DISEASES  OF  THE  DECIDUA.— DISEASES  OF  THE  OVUM. 


281 


contents  of  the  hernial  sac,  which  is  composed  of  the  amnion  and  of 
the  peritonaeum,  are  usually  convolutions  of  the  intestine,  or  these 
with  a  portion  of  the  liver,  although  the  kidneys,  stomach,  and  spleen 
are  sometimes  also  extruded,  leaving  the  fetal  abdomen  nearly  empty. 

IV.  Coiling  of  the  Cord. — Windings  of  the  umbilical  cord  around 
the  foetus,  occurring  during  pregnancy,  vary  in  their  results  with  the 
rapidity  of  their  formation.  When  rapidly  developed  they  may,  in 
rare  cases,  lead  to  sudden  interruption  of  the  umbilical  circulation, 
and  to  consequent  death  of  the  foetus.  Should  the  coils  be  gradually 
formed  and  firm,  the  extremity  embraced  by  the  cord  increases,  by  its 
own  growth,  the  tightness  of  the  constricting  ligature.  The  latter 
slowly  lessens  the  caliber  of  the  vessels  supplying  the  extremity  con- 
cerned, and  finally,  occluding  them,  produces  death  of  the  limb.  Ab- 
sorption of  the  soft  and  hard  parts  of  the  extremity  may  result  from 
the  cord's  unyielding  pressure,  and  the  limb  be  thus  completely 
severed  from  the  trunk  by  so-called  spontaneous  amputation.  In  cer- 
tain cases  the  combined  pressure  of  the  cord  and  of  the  slowly  grow- 
ing member  may  suffice  to  completely  arrest  the  umbilical  circulation, 
and  thus  produce  the  death  of  the  foetus.  Should  the  neck  be  encir- 
cled by  the  cord,  death  will  soon  ensue,  attended,  in  some  cases,  by 
almost  complete  amputation  of  the  head.  Coilings  of  the  cord  around 
the  foetus  occurring  at  birth  are  of  little  importance  unless  they  be 
numerous.  In  that  case  they  lead  to  a  shortening  of  the  cord,  and 
produce  anomalous  positions,  premature  separation  of  the  placenta, 
retarded  second  stage  of  labor,  and  even  death  of  the  foetus  from  inter- 
ference with  the  umbilical  circulation. 

V.  Cysts. — Cysts  of  the  umbilical  cord,  within  the  amniotic  sheath, 
are  either  produced  by  liquefaction  of  mucoid  tissue  or  by  accumula- 
tion of  serum  between  the  epithelial  layers  of  the  allantois. 

VI.  Stenosis  of  Umbilical  Vessels. — Partial  occlusion  of  the  um- 
bilical vein,  at  the  placental  insertion,  produced  by  new  connective 
tissue  resulting  from  circumscribed  periphlebitis,  is  sometimes  ob- 
served, but  is  not  sufficiently  marked  to  impede  the  umbilical  circula- 
tion. Stenosis  of  the  umbilical  arteries  is  occasionally  produced  by 
atheroma  and  subsequent  thrombosis.  Stenosis  of  the  umbilical  vein, 
and,  more  rarely,  of  tho  arteries,  may  also  result  from  chronic  phlebitis 
characterized  pathologically  by  the  growth  in  the  intima  of  spindle- 
shaped  and  round  cells  which,  later,  develop  into  new  connective 
tissue.  This  process,  which  is  usually  referred  to  hereditary  syphilis,* 
may  extend  into  the  muscularis,  and  even  invade  the  adventitia.  The 
result  of  the  stenosis  of  the  uterine  vessels  is,  of  course,  prejudicial  to 
the  foetus  in  direct  proportion  to  its  grade  of  development. 

VII.  Calcareous  Degeneration.  —  Calcareous  deposits  have  been 
observed  in  the  cords  of  syphilitic  foetuses. 

*  Mewis,  "Ztschr.  f.  Geburtsh.  u.  Gynaek.,"  Bd.  iv,  Heft  1,  1879,  p.  62. 


282 


THE  rATIIOLOGY  OF  PREGNANCY. 


VIII.  Marginal  Insertion  of  the  Cord.— This  anomaly  is  sometimes 
called  the  battledoor  jolacenta,  while  the  term  insertio  velamentosa  is 
applied  to  cases  where  the  vessels  of  the  cord  pursue  their  course  for 
some  distance  through  the  membranes  before  reaching  the  placenta. 


Fig.  139. — Insertio  velamentosa.  (Lobsteln.) 


To  comprehend  their  origin,  it  is  necessary  to  recall  the  main  physio- 
logical processes  involved  in  the  normal  development  of  the  placental 
organ.  The  vessels  of  the  allantois  are  not  invariably  carried  at  tlie 
outset  to  the  point  in  the  periphery  of  the  ovum  which  the  placenta 
will  ultimately  occupy.  The  vessels  at  first  penetrate  all  the  villi  in- 
discriminately, but,  as  the  process  of  obliteration  advances  in  those 
villi  not  destined  to  participate  in  the  formation  of  the  placenta,  vas- 
cular connections  are  only  preserved  between  the  vessels  of  the  newly 


DISEASES  OF  THE  DECIDUA.— DISEASES  OF  THE  OVUM.  283 

formed  cord  and  the  villi  attached  to  the  serotina.  As  the  amniotic 
sheath  forms  around  the  rudimentary  cord,  the  foetus  performs  a 
movement  of  rotation  in  such  a  way  that  the  umbilical  vessels  are 
made  to  pursue  a  direct  course  toward  their  placental  insertion.  If, 
owing  to  adhesions  between  the  rudimentary  cord  and  either  the 
chorion  or  the  amnion,  the  formation  of  the  sheath  is  incomplete,  the 
vessels  diverge,  and  are  distributed  to  j)oints  more  or  less  distant  from 
the  placenta  (Schultze). 

Hydatidiform  Mole. 

I.  Morbid  Anatomy. — Before  the  time  of  Cruveilhier,  who  is  said  to 
have  first  demonstrated  the  difference  between  true  hydatids  and  the 
uterine  hydatidiform  mole,  these  morbid  formations  were  regarded  as 
identical.  Since  his  researches,  it  has  been  considered  established  that 
the  essential  pathological  process  involved  in  the  production  of  the 
hydatid  mole  consists  in  a  proliferative  degeneration  of  the  chorionic 
villi.  This  degeneration  of  the  villi  embraces  hypertrophy  of  their 
investing  epithelium,  of  their  connective-tissue  cells,  which  may  also 
undergo  mucoid  degeneration,  and  of  their  mucoid  intercellular  sub- 
stance. The  accumulation  of  the  mucoid  tissue  imparts  to  the  villi 
the  appearance  of  cysts  with  translucent,  semi-fluid  contents,  varying 
in  size  from  that  of  a  millet-seed  to  that  of  a  walnut,  and  forming,  by 
their  aggregation,  growths  which  may  attain  the  dimensions  of  a  child's 
head,  or  in  rare  cases  may  reach  such  proportions  as  to  distend  the  ute- 
rus to  the  size  usual  at  the  full  term  of  pregnancy.  Smaller  collections 
are  much  more  frequently  encountered  than  those  of  these  enormous 
proportions.  The  fluid  of  the  cysts  is  albuminous  and  closely  resem- 
bles the  liquor  amnii,  but  contains  in  the  earlier  stages  a  larger  pro- 
portion of  mucin  than  the  latter.  At  a  later  period  the  mucin  is  less 
abundant,  while  the  albumen  increases  in  quantity.  The  larger  cysts 
are  richer  in  water,  but  contain  less  mucin,  than  the  smaller  ones. 
Inasmuch  as  the  degenerative  process  does  not  attack  the  entire  villus, 
portions  of  normal  tissue  intervene  between  the  cysts,  and  impart 
to  the  degenerated  mass  the  appearance  of  grape-clusters — the  cysts 
representing  the  individual  berries,  and  the  unaltered  tissues  their 
connecting  stems.  A  certain  number  of  cysts  are,  however,  attached 
to  a  single,  continuous  pedicle,  instead  of  possessing  a  separate  stem 
connected  with  a  common  trunk,  as  is  the  case  in  the  grape-cluster. 
If  the  mole  be  formed,  as  is  usually  the  case,  during  the  first  month, 
while  the  villi  are  equally  developed  upon  the  entire  periphery  of  the 
ovum,  the  degeneration  will  involve  its  whole  surface.  In  this  case 
the  fo)tus,  dying  and  becoming  disintegrated,  may  undergo  complete 
absorption,  leaving  the  amniotic  cavity  empty.  The  vessels  of  the 
villi  are,  under  such  circumstances,  completely  obliterated,  while  nu- 
merous blood-coagula  are  found  between  the  cysts.    If,  however,  the 


284 


THE  PATHOLOGY  OF  PREGNANCY. 


placenta  be  already  formed  at  the  beginning  of  the  cystic  degenera- 
tion, the  villi  having  already  become  atrophied  upon  that  part  of  the 
chorion  not  participating  in  the  development  of  the  placenta,  the 


esting  case  reported  by  Volkmann,  however,  f  the  degenerated  villi 
had  invaded  the  uterine  blood-sinuses,  and  by  pressure  led  to  so 
extensive  an  atrophy  and  absorption  of  the  uterine  walls  as  to  leave 
only  a  thin,  transparent  septum  between  the  mole  and  the  perito- 
neal covering  of  the  organ.  The  cavity  formed  by  this  process  of 
erosion  in  the  uterine  parenchyma  was  larger  than  the  uterine  cav- 
ity proper,  and  presented  numerous  intersecting  trabeculae  resembling 
the  column 86  carneae  of  the  cardiac  ventricles.  The  destructive  char- 
acter of  the  cystic  degeneration  is  attributed  in  such  cases  to  some 
unknown  morbid  condition  of  the  uterine  walls,  probably  the  result  of 
malnutrition.  Schroeder  I  refers  to  two  similar  cases,  in  one  of  which 
the  cystic  degeneration  was  attended  by  fatal  peritonitis  and  the  other 
by  rupture  of  the  uterus,  and  death  from  haemorrhage  into  the  peri- 
toneal cavity. 

II.  Etiology. — Primiparae  are  less  frequently  affected  by  the  hydatid- 

iform  mole  than  multiparas,  although  the  actual  number  of  pregnancies 
seems  to  exert  a  less  marked  predisposing  influence  than  advancing 
age.    The  cystic  degeneration  usually  occurs  during  the  first  month 


Fig.  140. — Hydatidiform  mole. 


neoplasm  is  confined  as  a  rule  to 
the  latter,  although  cysts,  evident- 
ly owing  their  origin  to  villi  which 
have  not  undergone  atrophy,  some- 
times occur  upon  the  smooth  sur- 
face of  the  chorion.  Should  the 
hydatidiform  mole  be  of  sufficient 
extent,  under  these  circumstances, 
to  destroy  the  foetus,  the  more  or 
less  disintegrated  remains  of  the 
latter  are  found  in  the  amniotic 
cavity,  which  sometimes  contains 
an  excess  of  liquor  amnii.  If  only 
a  few  of  the  placental  lobes  or 
single  cotyledons  be  implicated, 
the  growth  of  the  foetus  may  not 
be  disturbed.  A  healthy  foetus  is 
occasionally  developed  side  by  side 
with  a  hydatid  mole.*  The  hyda- 
tidiform mole  is  usually  contained 
within  the  decidua.    In  an  inter- 


*  SriKGELRKRG,  "  Lchrl)uch,"  p.  332. 

f  Volkmann,  Virchow's  "  Archiv,"  Bd.  xli,  p.  528. 

I  ScHROEDKR,  "  Lchrbuch,"  p.  429. 


DISEASES  OF  THE  DECIDUA.— CISEASES  OF  THE  OVUM. 


285 


of  utero-gestation.  According  to  Underhill,'^  the  latter  part  of  the 
third  month  is  the  limili  within  which  the  disease  can  originate.  That 
the  exciting  cause  of  the  hydatidiform  mole  may  be  a  morbid  maternal 
condition  is  rendered  probable  by  the  repeated  recurrence  of  the  dis- 
ease in  the  same  patient,  by  its  coexistence  with  inflammatory  decidual 
disease,  or  with  extensive  uterine  fibroids,  and  by  the  presence,  in  the 
majority  of  cases,  according  to  Underbill,  f  of  a  cancerous  or  syphilitic 
dyscrasia  on  the  part  of  the  mother.  If  the  origin  of  the  degeneration 
be  maternal,  as  it  probably  is  in  most  instances,  the  degeneration  of 
the  chorion  antedates  and  produces  the  death  of  the  foetus.  On  the 
other  hand,  the  fact  that  the  morbid  growth  may  owe  its  inception  to 
foetal  disease  seems  demonstrated  by  those  cases  in  which,  as  has  been 
already  stated,  a  healthy  foetus  may  be  developed  in  the  same  amniotic 
cavity  with  a  hydatidiform  mole.  This  view  is  further  supported  by 
those  cases  in  which  death  of  the  foetus  is  attended  by  so  insignificant 
an  amount  of  chorionic  disease  as  to  render  its  active  causative  agency 
in  the  death  of  the  foetus  highly  improbable.  Spiegelberg  J  is  of  the 
opinion  that  the  hydatidiform  mole  does  not  result  from  death  of  the 
embryo,  and  that  its  cause  is  often  to  be  sought  in  an  abnormal  devel- 
opment of  the  allantois.  The  establishment  of  the  true  pathological 
relations  of  the  hydatidiform  mole  have  led  to  the  abandonment  of 
the  once  prevalent  opinion  that  the  neoplasm  might  be  developed 
independent  of  conception.  The  theory  that  a  portion  of  retained 
placenta  might  become  affected  with  the  hydatidiform  disease  has  also 
been  refuted  by  accumulated  clinical  evidence. 

III.  Symptomatology. — A  leading  sign  of  the  hydatidiform  mole 
consists  in  a  failure  of  correspondence  between  the  uterine  enlarge- 
ment and  the  computed  period  of  utero-gestation.  The  uterus  is 
usually  larger  at  any  given  stage  of  pregnancy  than  it  naturally  would 
be  in  the  course  of  normal  gestation,  but  may  be  decidedly  smaller  in 
those  cases  attended  by  early  demise  of  the  embryo.  Lumbar  and 
sacral  pains  are  prominent  and  distressing  in  proportion  to  the  rapid- 
ity of  uterine  development.  The  uterus  imparts  a  peculiar  doughy 
feeling  to  the  palpating  fingers,  and  in  rare  instances  j)lainly  percep- 
tible fluctuation.  Individual  parts  of  the  foetus  can  not  be  distin- 
guished through  the  uterine  walls.  The  lower  segment  of  the  uterus 
is  remarkably  tense.  Ballottement  yields  negative  results  and  fetal 
movements  are  absent,  although  they  may  be  closely  simulated  by 
uterine  contractions.  The  fetal  cardiac  sounds  are  diminished  in 
intensity  or  quite  imperceptible.  There  is  a  discharge  from  the  uterus, 
either  constant  or  intermittent,  consisting  of  disintegrated  and  unrupt- 
ured cysts,  cystic  fluid,  and  blood,  which,  although  usually  not  exces- 
sive, may  be  so  much  increased  by  uterine  contractions,  induced  by 

*  Underhill,  "The  Ilytlatldiform  Mole,"  "Obstet.  Gaz.,"  January,  1879,  p.  16. 
f  Undmihill,  loc.  cit.,  p.  5.  if  Spiegelberg,  "  Lchrbuch,"  p.  333. 


286 


THE  PATHOLOGY  OF  PREGNANCY. 


over-distention,  as  to  seriously  impair  the  general  strength,  or  even  to 
induce  death  from  exhaustion. 

Abortion  is  usually  produced  by  the  mole  before  the  sixth  month, 
but  the  expulsion  of  the  neoplasm  may  be  delayed  until  the  normal 
period  of  parturition,  or  even  until  a  later  season.  The  haemorrhage 
and  the  characteristic  discharge  cease  after  the  complete  expulsion  of 
the  tumor,  but  retained  portions  of  the  same  may  give  rise  to  protracted 
bleeding.  It  is  often  impossible  to  distinguish  the  local  signs  pro- 
duced by  the  expulsion  of  a  large  hydatidiform  mass  from  those  ob- 
served after  normal  delivery. 

Diagnosis. — In  cases  of  limited  cystic  degeneration  it  is  often 
impossible  to  diagnosticate  hydatidiform  mole.  The  symptoms  upon 
which,  in  well-marked  cases,  the  diagnosis  is  to  be  based  are  rapid  in- 
crease in  the  dimensions  of  the  uterus,  the  presence  of  obscure  fluctu- 
ation, the  impossibility  of  obtaining  the  fetal  heart-sounds,  or  of 
grasping  any  of  the  fetal  members,  negative  result  of  laUoUement,  and 
uterine  contractions,  attended  by  the  mucous  or  muco-sanguinolent 
discharge  containing  the  characteristic  cysts. 

Prognosis.  —  The  prognosis  of  hydatidiform  mole  is  determined 
chiefly  by  the  frequency  and  the  violence  of  the  attending  haemor- 
rhages. It  is  not  extremel  y  unfavorable  in  the  majority  of  cases. 
The  existence  of  the  peculiar  form  of  cystic  degeneration  described 
a3  the  interstitial,  intra-parietal,  or  eroding  variety  would ,  however, 
naturally  render  the  prognosis  exceedingly  grave.  The  fatality 
of  this  class  of  cases  results  from  their  tendency  to  produce  a  rup- 
ture of  the  uterus  complicated  by  intra-peritoneal  hsemorrhage, 
peritonitis,  or  septicaemia.  The  life  of  the  foetus  is  almost  invariably 
sacrificed. 

Treatment. — The  treatment  is  restricted  to  measures  calculated  to 
control  hsemorrhage,  and  to  promote  the  expulsion  of  the  diseased 
mass.  Most  writers  recommend  non-interference  so  long  as  the  ute- 
rus remains  passive.  When,  however,  contractions  set  in,  the  vagina 
should  be  tamponed,  and  ergot  given  in  full  and  repeated  doses,  until 
the  mole  is  expelled  entire.  The  expectant  plan  is,  however,  not  de- 
void of  danger.  In  one  case,  where  the  patient  suffered  from  labor- 
pains  for  several  hours  before  I  saw  her,  the  loss  of  blood  was  exces- 
sive. I  succeeded  in  removing,  with  the  hand,  through  the  patulous 
cervix,  an  enormous  quantity  of  cysts,  sufficient  to  fill  a  wooden  pail. 
This  was  followed  by  good  contraction  of  the  uterus  and  arrest  of  the 
liaemorrhage,  but  the  patient  died  two  hours  later  from  shock  and 
anaemia.  Unless,  therefore,  the  patient  is  so  placed  that  professional 
assistance  can  be  obtained  at  a  moment's  notice,  the  propriety  of  di- 
lating the  cervix  so  soon  as  the  diagnosis  has  been  established  may 
v/ell  be  considered.  Dilatation  should  be  effected  by  the  finger,  or  by 
the  dilators  of  Molesworth,  of  Barnes,  or  of  Tarnier,  rather  than  by 


DISEASES  OF  THE  DECTDUA.— DISEASES  OF  THE  OVUM.  287 


tents,  because  of  the  tendency  of  the  latter  to  increase  the  dangers  of 
septicaemia. 

After  expulsion,  or  after  the  manual  removal  of  the  hydatidiform 
cysts,  the  uterus  should  be  washed  out  with  antiseptic  fluids,  or,  in 
case  of  haemorrhage,  its  inner  surface  should  be  swabbed  with  the  per- 
chloride  of  iron.  The  irrigation  of  the  uterine  cavity  with  water,  to 
which  only  sufficient  perchloride  of  iron  has  been  added  to  give  it  a 
wine-color,  has  often  a  powerful  styptic  effect.  Underhill  recom- 
mends the  continued  employment  of  ergot  after  delivery,  and,  in 
cases  of  persistent  haemorrhage,  the  occasional  introduction  of  the 
laminaria  tent,  and,  if  necessary,  the  employment  of  Thomas's  dull- 
wire  curette. 

Retei^tiox,  IX  Utero,  of  the  Dead  Fcetus. 

The  causative  conditions  producing  retention  of  the  dead  foetus 
are  not  invariably  identical.  If  the  placenta  remain  adherent  to  the 
uterus  after  the  demise  of  the  foetus,  the  continued  vitality  and  unin- 
terrupted development  of  the  placenta  sufficiently  explain  the  fetal 
retention.  When,  however,  all  connection  bjetween  the  placenta  and 
the  uterus  has  been  severed,  retention  is  probably  referable  to  the 
diminished  irritability  of  those  reflex  nervous  centers  which  control 
the  expulsive  uterine  efforts.  The  duration  of  retention  produced  by 
adhesion  of  the  placenta,  in  cases  of  single  pregnancy,  is  protracted 
until  such  time  as  morbid  placental  processes  impair  the  vitality  of 
that  organ  and  induce  its  separation.  In  multiple  pregnancies,  at- 
tended by  death  of  one  or  more  of  the  foetuses,  the  latter  are  usually 
expelled  with  the  healthy  foetus  at  term.  They  are,  however,  some- 
times expelled  earlier,  and,  in  rare  instances,  later  than  the  normal 
foetus,  and  it  may  in  general  terms  be  stated  that  retention  produced 
by  placental  adhesion  very  rarely  exceeds  the  natural  period  of  gesta- 
tion. Retention  due  to  diminished  irritability  of  the  reflex  centers 
may  be  indefinitely  prolonged.  Liebmann  *  is  of  the  opinion  that  all 
cases  of  retention  protracted  beyond  the  normal  term  of  pregnancy 
belong  in  this  category. 

The  pathological  changes  which  the  foetus  undergoes  when  retained 
in  the  uterus  after  its  death  vary  with  the  condition  of  the  membranes  : 
1.  If  their  integrity  be  preserved,  the  most  important  pathological  fetal 
conditions  resulting  from  the  retention  are  mummification,  maceration, 
fatty  degeneration,  and  calcification,  f  2.  If  the  membranes  be  rupt- 
ured soon  after  the  death  of  the  foetus,  or  if  their  rupture  be  the 
cause  of  the  termination  of  fetal  life,  that  form  of  degeneration  to  be 
presently  described  as  mummification  may  ensue  ;  calcareous  degenera- 
tion may,  as  in  the  first  instance,  result  in  the  formation  of  a  lithopae- 

*  Liebmann,  "Bcitrag  z.  Geburtsh.  n.  Gynaclc,"  Bd.  iii,  1874,  pp.  59,  63. 
f  EuLENKAMrp,  "Retcnt.  asgestorbcnen  Fruchte  in  Utero,"  Kiel,  1874,  p.  22. 


288 


THE  PATHOLOGY  OF  PREGNANCY. 


dion,  or,  in  the  event  of  the  entrance  of  air  into  the  uterine  cavity, 
the  fetal  tissues  may  undergo  putrefactive  changes.  If  mummification 
has  already  occurred,  putrefaction  does  not  take  place.* 

Mummiftcation. — Mummification  is  most  frequently  observed  in  foe- 
tuses whose  death  has  apparently  been  the  gradual  result  of  inanition 
from  inadequate  blood-supply,  this  insufficiency  of  the  nutritive  fluid 
being  often  referable  to  torsion  or  constriction  of  the  umbilical  cord. 
Mummification  affects,  by  preference,  foetuses  dying  during  the  middle 
stages  of  gestation.  Liebmann  f  suggests  that  this  fact  may  be  con- 
nected with  the  augmented  rapidity  of  endosmosis,  due  to  the  larger 
percentage  of  saline  ingredients  then  present  in  the  amniotic  fluid, 
or  to  the  fact  that  torsion  and  stenosis  of  the  cord  are  most  liable  to 
occur  at  that  period  of  pregnancy.  Mummification  occurs  chiefly  in 
connection  with  twin  pregnancies,  J;  one  foetus  being  fully  developed 
while  the  other  becomes  mummified.  In  this  case  the  presence  of  the 
dead  foetus  does  not  usually  excite  expulsory  uterine  efforts  before  the 
normal  termination  of  pregnancy  is  reached,  when  both  foetuses  are 
simultaneously  delivered.  In  certain  rare  instances  the  mummified 
foetus  may  be  expelled  either  before  or  after  the  healthy  one,  but  its 
delivery  is  unattended  by  haemorrhage  or  other  unpleasant  complica- 
tion. When  mummification  affects  a  single  foetus,  the  retention  is 
supposed  to  be  due  to  abnormally  intimate  connection  between  the 
placenta  and  the  uterus.  Symptoms  closely  simulating  those  of  abor- 
tion occur,  but  they  subside  before  the  product  of  conception  is  ex- 
pelled, and  probably  even  before  the  rupture  of  the  membranes.  The 
foetus  then  becomes  mummified,  while  the  vitality  of  the  placenta  is 
not  impaired.  Under  these  circumstances  the  retention  is  never  pro- 
longed beyond  the  normal  period  of  gestation,  and  is  thus  distinguished 
from  those  cases  of  retention  owing  their  origin  to  so-called  ^'missed 
labor." 

A  mummified  foetus  is  flattened  from  compression.  Its  viscera  are 
of  soft  consistency  and  of  small  dimensions.  Its  surface  is  shrunken. 
The  peritoneal  and  pleural  cavities  contain  a  scanty  and  discolored 
fluid.  The  subcutaneous  areolar  tissue  has  disappeared,  and  the  skin 
lies  in  direct  contact  with  the  muscles.  The  placenta,  which  is  dry, 
yellowish,  and  tough,  is  the  seat  of  fatty  degeneration,  and  contains  the 
residue  of  old  extravasations. 

Maceration. — The  placenta  of  a  macerated  foetus  is  ana3mic,  soft, 
and  friable.  The  cord,  in  which  the  vessels  are  permeable,  is  cylin- 
drical, smooth,  spongy,  and  inelastic.  Its  coils  have  disappeared.  It 
is  club-shaped  at  the  fetal  extremity,  and  its  color  is  brownish-red. 
The  amniotic  fluid  has  a  peculiarly  repulsive,  sweetish,  and  sickening 

*  Spiegelberg,  "Lehrb.,"  p.  307.  f  Liebmann,  op.  cit.,  p.  54. 

X  McCall,  "Transactions  of  Philadclpliia  Obstetrical  Society,"  "American  Journal  of 
Obstetrics  and  Diseases  of  Women  and  Children,"  vol.  viii,  p.  554. 


DISEASES  OF  THE  DECIDUA.— DISEASES  OF  THE  OVUM. 


289 


odor,  unlike  that  of  putrefaction.  The  fluid  is  rendered  turbid  and 
of  a  greenish-yellow  color  by  the  admixture  with  it  of  sero-sanguino- 
lent  fluid,  and  of  meconium.  The  membranes,  which  retain  their 
normal  consistence  for  a  long  time,  finally  become  friable,  swollen,  and 
discolored.  A  foetus  of  only  one  to  two  months  may  be  completely  dis- 
solved by  the  process  of  maceration.  If  the  foetus  be  more  mature,  its 
general  form  and  the  outline  of  its  organs  are  preserved,  but  granular 
degeneration  and  disintegration  of  their  anatomical  elements  are  every- 
where present.  The  epidermis  is  first  affected  by  the  process  of  macer- 
ation. It  is  separated  from  the  corium  by  the  formation  of  vesicles, 
similar  to  those  of  pemphigus,  which  contain  either  a  reddish,  sero- 
sanguinolent,  or  a  clear  serous  fluid.  The  corium  is  infiltrated  with 
the  same  fluid,  and  presents  the  appearance  of  brownish-red  macerated 
parchment.  The  subcutaneous  areolar  and  adipose  tissues  are  reddish 
and  oedematous.  The  oedema  is  most  apparent  over  the  cranium,  the 
abdomen,  the  feet,  hands,  and  sternum.  The  entire  body  is  flaccid, 
and  assumes,  under  the  influence  of  external  pressure,  curiously  dis- 
torted shapes,  being  distended  at  some  points,  and  depressed  or  flat- 
tened at  others.  The  cranial  sutures  are  separated,  the  joints  are 
disarticulated,  and  the  periosteum  has  become  detached  from  the  long 
bones.  The  vessels  are  filled  with  dark,  grumous  blood.  The  serous 
cavities  are  distended  with  bloody  serum.  The  brain  is  transformed 
into  a  grayish-red  pulp.  All  the  viscera  are  infiltrated  and  friable,  the 
uterus  and  lungs  preserving  their  normal  consistence  longer  than  the 
other  organs.  Pigment  masses  and  fat-crystals  are  deposited  in  many 
organs.  Sometimes  the  accumulation  of  fat  is  so  abundant  that  the 
term  fatty  degeneration  is  applicable  to  the  process  of  its  deposition. 
No  trustworthy  inferences  can  be  drawn  from  the  appearance  of  macer- 
ated foetuses  as  to  the  cause  of  their  decease,  since  the  gross  patho- 
logical conditions  are  identical  under  all  circumstances.*  Apparent 
variations  are  due  to  the  respective  periods  of  retention.  The  rapidity 
with  which  the  process  of  maceration  occurs  is  variable,  and  its  extent  is, 
therefore,  no  criterion  of  the  time  at  which  the  fetal  demise  took  place. 

Seventy-five  per  cent,  of  macerated  foetuses  are  expelled,  according 
to  Ruge,t  before  the  thirty-first  week,  and  transverse  or  breech-pres- 
entations occur  in  nearly  one  half  of  all  the  cases. 

The  cases  in  which  the  dead  foetus  is  retained  in  utero  after  the  ex- 
piration of  the  normal  period  of  gestation  differ  in  symptomatic  events 
and  pathological  conditions  from  those  already  considered.  In  these 
cases  the  death  of  the  foetus  may  have  occurred  either  in  the  earlier  or 
in  the  very  latest  stages  of  pregnancy,  and  the  retention  may  extend 
over  months  or  years. 

The  term  missed  labor  is  applied  to  those  cases  in  which,  the  uter- 
ine expulsive  efforts  having  been  ineffectually  made  at  full  term,  with- 

*  RuGE,  "  Zeit.  f.  Geb.  u.  Gyn.,"  Bd.  i,  Heft  1,  18V7,  p.  58.  f  lUd.,  p.  '70.. 

19 


290 


THE  PATHOLOGY  OF  PREGNANCY. 


out  other  result  than  the  escape  of  the  waters,  the  uterine  contractions 
finally  subside,  leaving  the  foetus  still  in  utero.  The  causes  of  missed 
labor  usually  cited  are  abnormal  absence  of  uterine  irritability,  or  of 
that  residing  in  the  reflex  nervous  centers,  obstructed  labor,  and  un- 
usually close  adhesions  of  the  placenta.  The  pathological  processes 
presenting  themselves  in  cases  of  long-continued  retention  and  of 
missed  labor  vary  with  the  entrance  of  air  into,  or  exclusion  of  air 
from,  the  uterine  cavity. 

If  the  atmosphere  have  free  access  to  the  uterus,  the  foetus  under- 
goes putrefactive  changes.  The  soft  parts,  having  been  liquefied,  es- 
cape, leaving  the  osseous  framework  of  the  foetus  in  utero.  This  may 
also  be  gradually  and  partially  disintegrated,  liquefied,  and  expelled, 
but  its  complete  evacuation  is  not  often  effected  by  Nature's  processes. 
If,  however,  the  cervix  be  narrow  or  unyielding,  the  continuous  press- 
ure of  some  projecting  and  pointed  bone  may  penetrate  its  tissues  and 
force  an  exit  through  the  vagina,  rectum,  or  anterior  abdomiral  wall. 
A  similar  irritation  and  penetration  may  induce  suppurative  metritis, 
and,  eventually,  fatal  peritonitis,  or  septicaemia. 

If  the  air  be  excluded  from  the  uterus,  in  cases  of  retention  indefi- 
nitely prolonged,  the  foetus  either  becomes  mummified,  and,  forming 
intimate  connections  with  the  uterus  through  the  medium  of  inflam- 
matory products,  remains  i7i  utero  without  giving  rise  to  any  symp- 
toms, or  it  may  produce  by  constant  irritation  suppurative  metritis, 
with  abscess  formation  and  the  escape  of  pus  externally.  Access  hav- 
ing been  thus  afforded  to  the  air,  putrefaction  and  its  consequences 
will  then  ensue. 

In  rare  cases  of  prolonged  retention,  the  foetus  becomes  the  seat  of 
fatty  and  calcareous  degeneration.  In  the  latter  case  it  is  designated 
by  the  term  lithopaedion. 

The  retention  of  the  dead  foetus  is  comparatively  devoid  of  danger. 
Even  if  decomposition  or  putrefaction  of  the  fcBtus  occurs,  the  prod- 
ucts of  disintegration  are  usually  eventually  eliminated  without  a 
fatal  result,  by  natural  efforts  or  by  the  intervention  of  obstetrical  art. 
Hein  *  recommends  the  colporynter  and  the  internal  administration  of 
ergot  as  effective  means  for  securing  the  expulsion  of  the  foetus.  In 
place  of  the  colporynter,  a  large  Barnes  dilator,  introduced  into  the 
vagina  and  filled  with  fluid,  may  be  employed. 

*  Hein,  "Beitr.  zur  Geburtshulfc,"  Bd.  ii,  p.  172. 


THE  PREMATURE  EXPULSION  OF  THE  OVUM. 


291 


CHAPTER  XVL 

THE  PREMATURE  EXPULSION  OF  THE  OVUM. 

Causes  of  abortion. — Disposition  to  abortion. — Immediate  causes. — Symptoms. — Moles. — 
Incomplete  abortions.  —  Dia^osis. — Prognosis. — Treatment. — Prophylaxis. — Arrest 
of  threatened  abortion. — Treatment  of  inevitable  abortion. — Treatment  of  neglected 
abortion. — Removal  of  fibrinous  polypi. — Treatment  of  miscarriage. 

Whex  pregnancy  is  interrupted,  during  the  first  three  months,  by 
uterine  contractions  leading  to  the  expulsion  of  the  ovum,  the  term 
abortion  is  used  ;  in  the  fourth,  fifth,  sixth,  and  seventh  months,  i.  e., 
from  the  formation  of  the  placenta  to  the  time  the  child  becomes 
viable,  it  is  proper  to  speak  of  the  accident  as  immature  delivery,  or 
miscarriage  ;  and,  finally,  a  confinement  occurring  from  the  twenty- 
eighth  week,  the  earliest  period  of  viability,  to  the  thirty-eighth  week, 
when  the  foetus  possesses  every  indication  of  maturity,  is  distinguished 
as  premature  delivery. 

This  purely  artificial  division  is  justified  by  practical  difiierences 
in  the  symptomatology  and  treatment  of  the  groups  thus  separately 
designated. 

Causes  which  lead  to  the  Premature  In-terruption"  of  Preg- 

KANCY. 

The  underlying  causes  of  abortion,  miscarriage,  and  premature 
delivery  are  the  same.  Causes  of  abortion  are  rarely  of  sudden  occur- 
rence. Usually  the  way  is  prepared,  either  by  changes  taking  place 
in  the  ovum,  or  by  certain  pathological  conditions  affecting  the 
mother.  In  either  of  these  ways  a  disposition  to  abortion  is  pro- 
duced. When  once,  as  the  result  of  morbid  changes,  the  attach- 
ment of  the  ovum  to  the  uterus  has  been  rendered  insecure,  causes 
usually  inoperative  suffice  to  determine  uterine  contractions  and  the 
time  at  which  the  expulsion  takes  place. 

The  Disposition  to  Abortion. — The  disposition  may  be  due  prima- 
rily to  any  disease  of  the  chorion,  of  which  we  have  an  example  in 
syphilitic  degeneration  of  the  villi  {vide  p.  276).  In  most  cases,  how- 
ever, death  of  the  foetus  precedes  and  leads  to  disease  of  the  chorion. 
The  causes  of  abortion  resolve  themselves,  therefore,  in  large  measure, 
into  the  causes  which  produce  death  of  the  foetus. 

The  death  of  the  foetus  may  be  due  to  direct  violence,  as  kicks  and 
blows  upon  the  abdominal  walls  ;  to  diseases  of  the  fetal  appendages 
(cord,  amnion,  chorion,  placenta) ;  to  diseases  of  the  decidua,  especially 
those  which  give  rise  to  haemorrhage  (before  the  complete  formation 
of  the  placenta,  the  separation  of  the  decidua  from  the  uterus  inter- 
feres with  the  nutritive  supplies  which  go  to  the  foetus) ;  to  febrile 


292 


THE  PATHOLOGY  OF  PREGNANCY. 


affections,  in  which  death  results  either  from  the  high  teniperature, 
from  associated  diseased  conditions  of  the  decidua,  or,  as  in  certain 
acute  infectious  diseases,  to  the  direct  transfer  of  the  poison  from  the 
mother  to  the  foetus  ;  and,  finally,  to  excessive  anaemia.  Ansemia  de- 
yeloped  by  pregnancy  rarely  affects  the  child.  In  acute  anaemia  from 
profuse  haemorrhage,  the  child  may  die  from  asphyxia.  In  times  of 
famine  great  numbers  of  women  abort.  The  disposition  to  abort  ob- 
served in  corpulent  women  is  probably  due  to  the  fact  that  the  blood 
is  insufficient  in  quantity  and  quality  to  supply  the  wants  of  the 
growing  child. 

The  death  of  the  foetus  is  followed  by  the  expulsion  of  the  ovum, 
not  usually  at  once,  but  after  a  longer  or  shorter  period  of  time.  Be- 
fore the  third  month,  in  such  cases  of  delay,  the  embryo,  which  con- 
sists of  hardly  more  than  a  heap  of  cells,  may  become  macerated,  and 
absorption  may  take  place  after  the  death  of  the  embryo.  Except  in 
cases  of  hydramnion,  partial  collapse  of  the  ovum  ensues.  As  soon  as 
the  foetus  dies,  the  circulation  which  passes  from  the  foetus  to  the  cho- 
rion and  placenta  is  suspended.  The  villi  then  become  obliterated, 
and  undergo  fatty  degeneration.  The  decidua  is  affected  by  the  same 
process.  With  the  diminution  in  the  volume  of  the  ovum,  contrac- 
tions begin.  The  villi,  loosened  in  their  attachments  to  the  decidua, 
are  drawn  out ;  and  the  decidual  vessels,  exposed  and  subjected  to  in- 
creased pressure,  rupture,  and  haemorrhage  results.  The  uterine  con- 
tractions are  awakened  and  exercise  an  expulsive  force  upon  the  ovum, 
which  in  its  descent  expands  the  cervix  from  above  downward,  and 
passes  finally  into  the  vagina.  In  the  first  three  months  the  ovum  is 
not  infrequently  expelled  with  membranes  unruptured.  From  the 
end  of  the  third  month  onward  such  an  occurrence  is  rare,  though  I 
have  seen  an  instance  which  happened  in  the  sixth  month.  In  the 
early  months  the  exjDulsion  of  an  intact  ovum  is  associated  with  incon- 
siderable haemorrhage.  When  the  membranes  give  way,  the  embryo 
and  the  fluid  contents  of  the  amnion  escape  first.  With  the  removal 
of  the  compression  exercised  by  the  ovum  upon  the  inner  surface  of  the 
uterine  walls,  haemorrhage  occurs,  which  continues,  as  a  rule,  until 
the  complete  expulsion  or  removal  of  the  membranes  and  placenta. 

Aside  from  the  death  of  the  foetus,  with  consecutive  changes  in 
the  chorion  and  decidua,  and  diseases  of  the  fetal  appendages  leading 
to  death  of  the  foetus,  the  predisposition  to  abortion  may  be  the  result 
of  primary  defects  or  changes  in  the  decidua  alone.  Of  these  changes 
we  recognize  : 

1.  Atrophy  of  the  Uterine  Mucous  Membrane. — The  insufficient 
development  of  the  mucous  membrane  exercises  an  injurious  influence 
upon  the  development  of  the  ovum  in  cases  only  in  which  the  serotina 
and  the  reflexa  are  involved.  An  abnormally  small  and  undeveloped 
serotinal  surface  may  give  rise  to  a  small  placenta,  or  the  serotinal 


THE  PREMATURE  EXPULSION  OF  THE  OVUM. 


293 


Fig.  141. — Ovum,  with  imperfectly  developed 
decidua;  outer  surface  of  vera.  (Duncan.) 


attachment  may  be  of  siicli  limited  extent  that  the  mere  weight  of  the 
ovum  drags  it  downward  and  converts  it  into  a  long,  narrow  pedicle. 
At  other  times,  the  reflexa  may  be  but  partially  developed,  or  may  fail 
altogether,  and  then  the  ovum,  covered  only  by  the  chorion,  hangs  by 
a  pediculated  attachment  to  the  serotina. 

In  both  these  cases,  the  uterine  contractions,  in  place  of  at  once 
effecting  the  expulsion  of  the  ovum,  may  force  the  ovum  into  the 

cervix,  where  it  may  remain 
for  a  time,  nourished  by  the 
long  pedicle,  but  arrested  in 
its  further  descent  by  a  con- 
tracted OS  externum.  To  these 
cases  the  term  cervical  preg- 
nancy has  been  applied.  The 
cervix,  according  to  the  month 
of  pregnancy,  is  more  or  less 
spherically  distended,  and  the 
corpus  uteri  above  contracts 
down  to  nearly  normal  dimen- 
sions. As  the  cause  of  this  con- 
dition lies  chiefly  in  rigidity  of  the  os  externum,  it  occurs  most  fre- 
quently in  primiparae.  Even  with  a  patulous  os,  though  rarely,  a  cer- 
vical 2^regnancy  may  be  produced  by  the  resistance  and  firmness  of 
the  pedicle  attaching  the  ovum  to  the  uterus.* 

2,  Hypertrophy  of  the  Mucous  Membrane. — Thickening  of  the  mu- 
cous membrane  is  the  result  of  endometritis,  and  may  lead  to  abortion 
in  either  of  the  following  ways  :  The  several  forms  of  endometritis 
{vide  p.  270)  may  give  rise  to  affections  of  the  placenta,  and  thus  prove 
fatal  to  the  fcetus,  or  the  thinned,  dilated  vessels  of  the  diseased  de- 
cidua may  rupture,  and  produce  sanguineous  effusions  between  the 
membranes. 

The  frequency  of  abortion  in  displacements  of  the  uterus  is  prin- 
cipally dependent  upon  associated  endometritis.  In  anteflexion  of  the 
uterus,  sterility  is  common,  but  endometritis  and  abortion  are  rare. 
In  retroflexion,  on  the  contrary,  while  there  is  slight  obstacle  to  con- 
ception, the  congestion  of  the  uterine  walls  and  the  altered  conditions 
of  the  uterine  mucous  membrane  render  abortion  a  frequent  occur- 
rence. 

Rigidity  of  the  uterine  walls,  which  interferes  with  their  due  ex- 
pansion, may  lead  to  premature  uterine  contractions.  In  this  way  an 
imbedded  fibroid  or  carcinoma  may  ultimately  become  sources  of  abor- 
tion. Expansion  of  the  uterus  may  likewise  be  hindered  by  old  peri- 
toneal adhesions  or  pelvic  cellulitis. 

*  W.  ScHULEi.v,  "  Ucber  cervical  Schwangerschaf t,"  "  Ztschr.  f.  Geburtsh.  und  Gy- 
nack.,"  Bd.  iii,  H.  2,  p.  408. 


294 


THE  PATHOLOGY  OF  PREGNANCY. 


Finally,  there  remains  a  class  of  women  in  whose  cases  it  is  impos- 
sible to  detect  either  disease  of  the  ovum  or  of  the  genital  organs,  yet 
in  whom  abortion  occurs,  dependent,  so  far  as  our  present  knowledge 
goes,  upon  certain  ]3ersonal  conditions  of  nerve  irritability.  Physical 
and  psychical  sources  of  excitement,  which  would  be  of  small  moment 
in  some  women,  in  them  suffice  to  interrupt  pregnancy. 

Immediate  Causes  of  Abortion. — Changes  in  the  ovum,  other  than 
rupture  and  escape  of  the  amniotic  fluid,  rarely  lead  at  once  and  di- 
rectly to  abortion.  The  proximate  causes  which  induce  contractions, 
and  the  throwing  off  of  the  ovum,  reside  for  the  most  part  in  the  ma- 
ternal system.    They  consist  of  : 

1.  HypercBmia  of  the  Gravid  Uterus. — When  the  predisposing  causes 
have  operated  to  weaken  the  attachments  of  the  ovum  to  the  decidua, 
anything  which  determines  the  blood-currents  to  the  uterus  is  liable 
to  produce  extravasations  of  blood  around  the  ovum,  and  awaken  uter- 
ine contractions.  Because  of  this  fact  we  surround  patients  predis- 
posed to  abort  with  every  precaution  during  the  periodic  menstrual 
congestion  that  not  even  pregnancy  altogether  suspends.  Fevers,  in- 
flammatory aflections  of  the  genital  organs,  excesses  in  coitus,  hot 
foot-baths,  valvular  heart-lesions,  obstructions  to  the  circulation  of 
the  lungs  and  liver,  may  each  lead  to  rupture  of  the  decidual  vessels. 
More  frequently  rupture  follows  jars  to  the  body  from  vomiting,  cough- 
ing, and  straining,  from  railroad- journeys,  from  violent  exercise,  from 
falls,  and  the  like. 

The  importance  of  separating  the  predisposing  from  the  immediate 
causes  of  abortion  is  shown  by  the  impunity  with  which  often  per- 
fectly healthy  women,  with  no  abnormal  conditions  of  the  generative 
organs,  set  all  the  usual  restraints  at  defiance  with  the  intent  to  inter- 
rupt an  undesired  pregnancy.  M.  Brillaud  Laujardiere  relates  the 
case  of  a  peasant  who  took  his  wife,  while  enceinte,  behind  him  on 
horseback,  and  started  off  with  her  at  full  gallop  with  the  view  of  caus- 
ing her  to  miscarry.  Having  thus  thoroughly  shaken  her,  he  dropped 
her  suddenly  to  the  ground  without  slackening  his  speed.  This  brutal 
manoeuvre  he  repeated  twice  without  the  least  success.*  On  the  other 
hand,  women,  eager  for  offspring,  after  an  abortion,  sometimes  lay 
undue  stress  upon  slight  imprudences,  and  make  them  the  sources  of 
morbid  self-reproaches,  which  it  becomes  one  of  the  functions  of  the 
physician  to  allay. 

2.  Uterine  Contractions,  ^produced  by  Influences  ivliich  act  di- 
rectly through  the  Nerves. — Of  this  Ave  have  examples  in  the  contrac- 
tions awakened  by  frictions  of  the  uterus  through  the  abdominal 
walls,  in  the  reflex  contractions  produced  by  stimuli  applied  to  the 
breasts,  and  in  those  excited  by  strong  mental  emotions. 

Symptoms. — As  the  detachment  and  expulsion  of  the  ovum  can  not 

*  T.  Gallard,  "  Dc  I'avortcmcnt  au  point  de  vue  medico-legal,"  Paris,  p.  24. 


THE  PREMATURE  EXPULSION  OF  THE  OVUM. 


295 


possibly  take  place  without  rupture  of  the  decidual  or  placental  ves- 
sels, haemorrhage  becomes  the  constant  and  necessary  result  of  every 
abortion.  In  the  first  two  months  the  haemorrhage  resembles  that  of 
a  profuse  menstruation.  Pain  is  present,  in  part  due  to  uterine  con- 
gestion, in  part  to  the  expulsion  of  blood-clots  through  the  imperfectly 
expanded  cervix.  The  latter  pains  resemble  those  of  obstructive  dys- 
menorrhoea.  These  symptoms  last  from  four  to  five  days.  As  the 
ovum  passes  away  unnoticed,  enveloped  in  the  clots,  or  piecemeal 
with  the  decidua,  women  are  apt  to  regard  these  early  abortions  as  the 
normal  recurrence  of  a  retarded  menstrual  period. 

After  the  third  month  prodromal  symptoms  are  rarely  wanting. 
Among  these  may  be  mentioned  fullness  and  weight  in  the  pelvis,  sa- 
cral pains,  frequent  micturition,  periodic  labor-like  pains,  and  a  mu- 
cous or  watery  discharge.  These,  followed  by  haemorrhage,  indicate  a 
threatened  abortion.  The  haemorrhage,  if  slight,  may  cease,  and  the 
pregnancy  go  on  undisturbed.  Usually,  however,  the  haemorrhage 
increases  in  amount,  or  after  a  brief  cessation  recurs.  Contractions 
set  in,  which  become  more  and  more  pronounced,  until  finally  the  ovum 
is  expelled. 

In  a  typical  case  of  abortion,  in  which  the  ovum  is  thrown  off 
entire,  uterine  retraction  and  haemorrhage  unite  to  effect  the  progres- 
sive separation  from  below  upward  of  the  decidua  from  the  uterine 
walls.  The  ovum  then,  covered  by  the  reflexa  and  the  detached  de- 
cidua, is  gradually  pressed  downward,  and  dilates  first  tlie  os  internum, 
next  the  cervix,  and  finally  the  os  externum.  The  ovum  passes  into 
the  vagina,  covered  by  the  decidua  vera,  or  drags  the  inverted  decidua 
after  it.  The  emptied  uterus  then  retracts  down,  and  the  haemorrhage 
ceases.  The  aborted  ovum  is  surrounded  with  coagulated  blood.  In 
the  first  three  months,  when  the  death  of  the  embryo  has  preceded  by 
a  little  time  the  completion  of  the  abortion,  every  vestige  of  the  em- 
bryo may  be  found  to  have  disappeared.  Sometimes,  in  the  third 
month,  a  small  placenta  with  shrunken  umbilical  vessels  may  now  and 
then  be  met  with. 

When  the  extravasation  of  blood  upon  the  uterine  surface  of  the 
vera  is  considerable  in  amount,  the  vera  is  sometimes  broken  through, 
and  the  blood  effused  between  the  vera  and  reflexa.  Extravasation 
may  likewise  take  place  between  the  reflexa  and  chorion,  either  in 
consequence  of  the  rupture  of  the  reflexa,  or  from  a  haemorrhage  start- 
ing from  the  placenta,  which  finds  its  way  along  the  outer  surface  of 
the  chorion,  and  dissects  away  the  reflexa.  The  pressure  upon  the 
ovum,  unless  it  has  previously  undergone  collapse  as  a  result  of  the 
death  of  the  embryo,  leads  to  rupture  and  escape  of  the  amniotic  fluid. 
The  retained  fetal  and  matei'nal  membranes,  with  the  intervening  lay- 
ers of  coagulated  blood,  form  a  mass  termed  a  mole.  When  the  blood 
coagula  are  fresh,  tlie  mass  is  termed  the  mola  sanguinea  (blood- 


296 


THE  PATHOLOGY  OF  PREGNANCY. 


mole),  and  when  of  older  date  the  mola  carnosa  (fleshy  mole).  The 
cavity,  which  is  lined  by  the  amnion,  has  usually  an  irregular  surface. 
It  is  very  exceptional  for  extravasations  to  break  through  both  chorion 
and  amnion,  and  thus  form  clots  in  the  amniotic  cavity  itself.  Moles 
seldom  exceed  an  orange  in  size,  and  usually  are  expelled  between 
the  third  and  fifth  month. 

In  cases  where  abnormal  adhesions  attach  the  vera  and  serotina  to 
the  walls  of  the  uterus,  retained  portions  of  the  maternal  membranes 
may  remain  after  the  ovum  is  expelled.  In  another  class,  and  this  is 
the  rule  after  the  third  month,  the  fetal  members  rupture,  and  the 
embryo  escapes  with  the  liquor  amnii.  Wliile  ordinarily  the  re- 
tained portions  quickly  follow  the  discharge  of  the  ovum  or  embryo, 
it  frequently  happens  that  the  uterus  retracts  upon  its  contents,  the 
cervix  closes,  and  a  period  of  repose  follows.  There  is  then  produced 
what  is  commonly  known  as  an  incomplete  abortion. 

Incomplete  Abortion. — The  various  contingencies  arising  from  these 
cases  of  incomplete  abortion  are  thus  truthfully  depicted  by  Spiegel- 
berg  :  * 

1.  Most  frequently  haemorrhage  continues  at  intervals,  spontaneous 
elimination  gradually  taking  place  as,  through  retrograde  changes,  por- 
tions of  the  retained  membranes  become  successively  loosened  in  their 
attachments  to  the  uterus. 

2.  In  exceptional  cases  the  haemorrhage  ceases  for  a  time  entirely. 
For  days,  weeks,  and  even  months,  the  woman  appears  quite  well. 
Then  suddenly  strong  contractions,  accompanied  by  profuse  haemor- 
rhage, usher  in  the  elimination  of  the  fetal  dependencies.  In  a  case 
of  my  own,  three  months  elapsed  from  the  occurrence  of  the  first 
haemorrhage,  which  took  place  toward  the  end  of  the  third  month, 
and  was  quite  insignificant  in  amount,  before  the  abortion  was  com- 
pleted. Meantime,  as  there  were  progressive  abdominal  enlargement, 
supposed  quickening,  and  milk  in  the  breasts,  the  threatened  abortion 
was  believed  to  have  been  arrested.  Total  retention,  with  a  long  in- 
terval of  repose,  is  thought  to  be  due  to  complete  adherence  of  the 
placenta,  which  continues  to  receive  nutrient  supplies  from  the  uterus. 
Spiegelberg  believes  that  a  menstrual  period  is  the  usual  time  at  which 
the  discharge  of  the  retained  membranes  takes  place. 

3.  Of  more  frequent  occurrence  than  the  foregoing  is  the  putrid 
decomposition  of  the  retained  portions.  It  occurs  chiefly  in  cases 
where  there  is  more  or  less  complete  loss  of  organic  connection  between 
the  placenta  and  the  uterus.  Decomposition  in  the  non-adherent  por- 
tions is  produced  by  the  introduction  of  air  during  the  escape  of  the 
embryo,  or  through  the  subsequent  passage  of  the  finger  into  the  ute- 
rus, or,  where  portions  of  the  ovum  hang  down  into  the  vagina,  by 
absorption  of  septic  matter  from  the  vagina  upward  into  the  uterus. 

*  SriEGELBERG,  "  Lchrbuch  der  Geburtshiilfe,"  Jahr  ISYV,  p.  377. 


THE  PREMATURE  EXPULSION  OF  THE  OVUM.  297 

As  a  result  of  putrid  decomposition,  the  woman  is  exposed  to  septicae- 
mia, and  infection  of  thrombi  at  the  placental  site.  Fatal  results  are, 
however,  rare,  as  decomposition  is  usually  a  late  occurrence,  setting 
in,  as  a  rule,  only  after  protective  granulations  have  formed  upon 
the  uterine  mucous  membrane,  and  after  the  complete  closure  of  the 
uterine  sinuses.  Continuous  fever,  with  intercurrent  attacks  of  haem- 
orrhage, is,  however,  set  up,  but  passes  away  finally  with  the  gradual 
discharge  of  the  decomposed  particles,  while  the  threatening  symp- 
toms subside.  Still,  now  and  then  septic  processes  lead  to  an  unfavor- 
able termination.    Local  perimetritic  inflammation  is  a  common  event. 


Fig.  142. — Uterus,  with  basis  of  a  fibrinous  polypus  after  an  abortion.  (Friinkcl.) 


4.  Where  there  is  a  certain  degree  of  relaxation  with  enlargement 
of  the  uterine  cavity,  the  fibrine  of  the  extravasated  blood  may  become 
deposited  about  any  uneven  surface  within  the  uterus,  and  give  rise  to 
a  polypus-shaped  body,  suggestive  in  its  mode  of  development  of  the 


298 


THE  PATHOLOGY  OF  PREGNANCY. 


stalactite  formations  in  calcareous  caverns.*^  These  so-called  fibrinous 
polypi  generally  develop  around  the  debris  of  an  abortion,  such  as 
retained  bits  of  decidua,  placental  remains,  and  portions  of  the  fetal 
membranes.  In  some  cases,  likewise,  thrombi  projecting  from  the 
placental  site  become  the  base  of  a  loose  fibrinous  attachment.  Pla- 
cental polypi  give  rise  ultimately  to  bearing-down  pains,  and  inter- 
current haemorrhages.  They  may  even  decompose,  and  endanger  life 
by  septic  absorption. 

The  retrograde  changes  that  take  place  in  a  uterus  after  an  abor- 
tion correspond  to  those  which  occur  in  deliveries  at  full  term.  Where 
a  suitable  plan  of  treatment  is  not  adopted,  or  where  the  importance 
of  care  in  the  after-management  is  not  adequately  appreciated,  sub- 
involution is  apt  to  follow.  Of  all  sources  of  uterine  disease,  none 
takes  precedence  of  a  mismanaged  abortion. 

Diag'nosis. — The  diagnosis  is  based  upon  the  presence  of  pain, 
haemorrhage,  dilatation  of  the  cervix,  and  the  descent  of  the  ovum. 
When  the  ovum  can  be  felt  through  the  patulous  os,  the  demonstration 
is  of  course  complete.  A  soft  polypus  may,  however,  present  a  decep- 
tive resemblance  to  a  small  ovum.  In  all  cases  of  pregnancy  the  exist- 
ence of  haemorrhage  alone,  even  when  disassociated  from  other  symp- 
toms, renders  the  probabilities  of  abortion  sufficiently  great  to  call  for 
the  exercise  of  every  precaution.  It  is  not  easy  to  recognize  pregnancy 
in  the  early  months,  but  in  doubtful  cases  the  cessation  of  the  menses 
should  be  regarded  as  presumptive  evidence  of  its  existence. 

The  diagnosis  of  these  pathological  changes  in  the  ovum  and  de- 
ciduae  which  pave  the  way  for  abortion  can  not  be  made  out  with 
certainty  from  mere  subjective  symptoms.  Such  changes  may  be 
regarded  as  probable  when  the  size  of  the  uterus  does  not  correspond 
to  the  supposed  period  of  gestation.  Thus,  if  the  uterus  at  the  fifth 
month  was  no  larger  than  is  usual  at  the  third  month,  the  death  of 
the  embryo  with  arrest  in  the  development  of  the  ovum  would  be 
naturally  inferred. 

When  the  physician  is  summoned  to  a  case  of  haemorrhage  occur- 
ring during  pregnancy,  he  should  at  once  examine  the  clots,  where 
they  have  been  preserved,  for  traces  of  the  ovum.  The  clots  should 
be  broken  up  under  water,  and  a  careful  examination  made  for  floating 
fringes  of  villi.  The  ovum,  when  expelled  entire,  is  usually  enveloped 
in  layers  of  coagulated  blood,  so  that  without  thorough  search,  it  would 
easily  pass  unnoticed.  If  the  coagula  have  been  thrown  away,  and 
the  physician  finds  upon  his  arrival  the  cervix  closed,  so  that  he  can 
not  pass  his  finger  into  the  uterus  to  explore  its  cavity,  it  may  be  im- 
possible at  once  to  determine  whether  the  abortion  has  taken  place 
wholly  or  in  part,  or  whether  the  entire  ovum  still  remains  in  utero. 

*  FuANKEL,  "Ceitrag  zur  Lchrc  von  fibrinoscu  Polypcn,"  "  Arch.  f.  Gynaek.,"  Bd.  ii, 
p.  76. 


THE  PREMATURE  EXPULSION  OF  THE  OVUM. 


299 


The  subsidence  of  all  symptoms  points,  as  a  rule,  to  a  complete  emp- 
tying of  the  uterus,  or  to  an  arrest  of  the  abortion,  though  in  some 
cases  it  precedes  mole-formation.  A  renewal  of  the  haemorrhage  and 
the  absence  of  normal  involution  indicate  the  continuance  of  the  ovum 
in  the  uterus,  or  an  incomplete  abortion. 

Prognosis. — The  prognosis  takes  cognizance  of  course  of  the  results 
to  the  mother  only.  In  the  first  place,  it  may  be  laid  down  in  the  way 
of  broad  general  statement  that  all  cases  of  spontaneous  abortion  (i.  e., 
excluding  criminal  cases),  not  complicated  with  other  morbid  condi- 
tions, are,  under  suitable  medical  guidance,  devoid  of  danger.  But, 
in  the  second  place,  it  must  be  borne  in  mind  that  the  statement  is 
only  true  with  the  reservations  that  limit  it,  for  in  point  of  fact  the 
actual  number  of  deaths  from  abortion  is  by  no  means  inconsiderable. 
Thus,  the  deaths  from  this  cause  reported  to  the  Bureau  of  Vital  Sta- 
tistics of  Xew  York  City,  between  the  years  1867  and  1875,  inclusive, 
were  one  hundred  and  ninety-seven,"^  a  number  which  falls  short  in  all 
probability  of  the  truth,  by  reason  of  the  many  circumstances  which 
precisely  in  this  condition  tempt  to  concealment.  The  total  number 
of  deaths  during  the  same  period  from  metria  was,  according  to  the 
reports  rendered,  1,947.  Hegarf  reckons  one  abortion  to  every  eight 
to  ten  full-time  deliveries.  If  this  proportion  be  correct,  it  would 
seem  to  show  that  the  mortality  from  abortion  is  hardly  second  to  that 
from  puerperal  fever  itself. 

Death,  as  a  consequence  of  criminal  abortion,  is  especially  frequent. 
M.  Tardieu  found  that  in  one  hundred  and  sixteen  such  cases,  of  which 
he  was  able  to  ascertain  the  termination,  sixty  women  died.  I  But  even 
in  spontaneous  cases  death  may  take  place  from  haemorrhage,  from  sep- 
ticaemia, or  from  peritonitis.  In  many  instances  the  fatal  termination 
is  fairly  attributable  to  the  ignorance,  the  imprudence,  or  the  willful- 
ness of  the  patient.  How  far  the  dangers  of  abortion  may  be  neutral- 
ized by  proper  medical  assistance  is  best  shown  by  the  statistics  of 
large  hospitals.  Thus,  I  gather  from  the  reports  issued  by  Dr.  John- 
ston, during  his  seven  years  mastership  of  the  Rotunda  Hospital,  in 
Dublin,  that  in  two  hundred  and  thirty-four  cases  of  abortion  treated 
in  that  institution  there  was  but  one  death,  and  that  not  from  puer- 
peral trouble,  but  from  mitral  disease  of  the  heart.  Bellevue  Hospital 
is  the  receptacle  annually  of  a  tolerably  large  number  of  women  suffer- 
ing from  incomplete  abortions,  many  of  whom  enter  the  hospital  in  a 
very  unpromising  condition  from  either  excessive  haemorrhage  or  septic 
decomposition  of  the  retained  portions  of  the  ovum.    Yet,  of  the  many 

*  LusK,  *'  Nature,  Origm,  and  Prevention  of  Puerperal  Fever,"  "  Transactions  of  the 
International  Medical  Congress,"  P*hiladelphia,  p.  880. 

f  Hegau,  "  Beitrage  zur  Pathologic  des  Eies,"  "  Monatsschr.  f .  Geburtslc,"  Bd.  xxi 
(supplement),  p.  34. 

X  T.  Gallard,  "De  I'avortcment  au  point  de  vue  medico-legal,"  Paris,  1878,  p.  45. 


800 


THE  PATHOLOGY  OF  PREGNANCY. 


cases  whose  histories  I  find  in  the  record-books  of  the  hospital,  all 
have  ended  in  recovery. 

Treatment. — The  treatment  is  divided  into — 1.  Prophylaxis  in  cases 
of  habitual  abortion  ;  2.  Arrest  of  threatened  abortion  ;  3.  Means 
adopted  to  avert  the  dangers  of  a  progressing  abortion. 

Prophylaxis. — Prophylaxis  considers  the  cause  which  underlies,  in 
each  case,  the  disposition  to  repeated  abortion.  One  of  the  principal 
of  these  causes  is  syphilis  in  one  or  both  parents.  It  is  just  in  these 
cases  that  the  triumph  of  the  mercurial  treatment  has  been  most  com- 
plete. The  treatment  should  be  addressed  to  the  parent  affected,  or 
both  parents  should  be  subjected  to  the  same  treatment. 

Among  local  conditions  amenable  to  treatment  may  be  mentioned 
endometritis,  displacements,  and  perimetritic  inflammations.  In  re- 
troflexions and  retroversions,  the  best  results  often  follow  the  replace- 
ment of  the  uterus  and  the  employment  of  a  suitable  pessary.  No 
harm  results  from  the  use  of  pessaries  during  pregnancy.  They  should, 
however,  be  watched,  on  account  of  possible  vaginal  irritation.  After 
the  completion  of  the  third  month  they  should  be  removed,  as  the 
uterus  then  remains  in  place  without  artificial  assistance.  When  back- 
ward displacement  of  the  uterus  follows  abortion,  reposition  aids  nor- 
mal involution. 

In  carcinoma  and  large  fibroids,  treatment  is  powerless.  Where, 
in  such  cases,  sterility  does  not  exist,  happily  for  the  mother,  the 
associated  morbid  conditions  of  the  uterine  mucous  membrane  and 
the  rigidity  of  the  uterine  walls  lead  commonly  to  the  death  of  the 
ovum  and  premature  uterine  contractions.  Where  a  small  fibroid  in 
the  posterior  uterine  walls  leads  to  sterility  by  the  production  of  retro- 
flexion, a  pessary  may,  after  replacement,  at  times  be  used  with  benefit. 

One  abortion  sometimes  follows  another  in  rapid  succession  in 
newly  married  women.  While  the  first  abortion  may  have  been  due 
to  some  accidental  cause,  the  sequence  is  often  kept  up  by  a  morbid 
condition  of  the  endometrium,  generated  by  the  shortness  of  the  inter- 
val between  the  pregnancies,  which  does  not  allow  the  restoration  of 
the  membrane  to  a  normal  condition.  In  such  cases,  a  six  weeks' 
abstention  from  sexual  intercourse  may  be  usefully  enjoined. 

In  certain  diseases  of  the  placenta,  in  which  the  respiratory  func- 
tion of  the  organ  had  suffered  any  marked  diminution.  Sir  J.  Y. 
Simpson  believed  he  had  succeeded  in  averting  the  death  of  the  foetus 
by  increasing  the  oxygen  in  the  blood  of  the  mother,  through  the  ad- 
ministration of  chlorate  of  potash.*  Chlorate  of  potash  may  be  given 
in  doses  of  twenty  grains,  three  times  daily,  for  weeks  at  a  time,  with- 
out injury  to  the  mother.  Though  it  has  not  always  rendered  me  the 
hoped-for  service,  the  experience  of  other  physicians,  among  whom  I 

*  Sir  J.  Y.  Simpson,  "Obstetric  Memoirs,"  edited  by  Priestley  and  Storer,  Edinburgh, 
1865,  vol.  i,  p.  460. 


THE  PREMATURE  EXPUI^ION  OF  THE  OVUM. 


301 


may  mention  Dr.  Fordyce  Barker,  appears  favorable  to  its  employ- 
ment. 

In  the  class  of  cases  in  which  abortion  results  neither  from  disease 
of  the  ovum  nor  of  the  uterus,  but  seems  dependent  wpon  some  pe- 
culiar condition  of  nerve-irritability,  the  patient  should  not  only  avoid 
every  known  means  of  awakening  uterine  contractions,  but  should 
exercise  the  utmost  caution  at  the  recurrence  of  the  menstrual  epochs. 
Especially  at  the  terminations  of  the  second  and  third  months  a  week's 
quiet  in  bed  should  be  insisted  upon.  Dr.  E.  J.  Jenks  *  recommends 
the  viburnum  jDrunifolium  in  cases  where  the  habit  of  aborting  has 
been  formed.  He  writes  :  "  My  mode  of  prescribing  the  viburnum  is  to 
have  the  patient  take  from  a  half-teaspoonful  to  a  teaspoon  ful  of  the 
fluid  extract  four  times  a  day,  beginning  at  least  two  days  before  the 
menstrual  date,  and  continuing  it  not  only  during  the  usual  period  of 
the  menstrual  flow,  but  two  days  longer  than  that  discharge  continues 
when  the  woman  is  not  pregnant."  From  the  fourth  month  onward, 
the  danger  of  the  occurrence  of  abortion  rapidly  diminishes. 

The  Arrest  of  a  Threatened  Abortion. — Arrest  may  be  accomplished 
in  cases  in  which  the  death  of  the  ovum  has  not  taken  place,  and 
where  the  haemorrhage  arises  from  a  slight  detachment  only  of  the 
decidua  or  placenta. 

In  every  case  of  threatened  abortion  occurring  in  the  early  months, 
a  careful  examination  should  be  instituted  to  ascertain  whether  retro- 
flexion or  retroversion  exists.  In  the  genu-pectoral  position,  replace- 
ment is  easy.  If  the  fundus  is  slowly  raised  by  two  fingers  introduced 
into  the  vagina,  so  soon  as  the  horizontal  line  is  reached  the  uterus 
falls  forward  of  its  own  weight.  Eeplacement  alone,  in  certain  cases, 
suffices  to  relieve  the  congestion  which  furnishes  the  immediate  cause 
of  the  abortion. 

Pain  in  the  back  during  pregnancy  should  be  regarded  by  women 
as  a  warning  for  them  to  temporarily  abstain  from  their  ordinary  avo- 
cations. With  ever  so  slight  a  haemorrhage,  they  should  at  once  be 
made  to  lie  down  and  keep  perfectly  still.  Simple  turning  in  bed  may 
start  up  fresh  bleeding.  Restlessness  and  mental  excitement  should  be 
allayed  by  opiates  in  full  doses.  Ice  to  the  vulva,  cold  cloths  to  the 
abdomen,  and  the  internal  administration  of  haemostatics  are  not  indi- 
cated. The  fluid  extract  of  viburnum  prunifolium  is  recommended 
by  Dr.  Jenks,  in  teaspoonful-doses  every  two  or  three  hours,  as  long 
as  its  use  seems  to  be  demanded,  f  The  author's  somewhat  limited 
experience  has  appeared  favorable  to  the  claims  put  forth  for  the 
viburnum  as  a  uterine  sedative.  Where  the  foregoing  measures  prove 
successful,  it  is  a  safe  rule  to  keep  the  patient  in  bed  for  a  week  after 
the  final  disappearance  of  the  threatening  symptoms. 

*  Jknks,  "Viburnum  Prunifolium,"  "Trans,  of  the  Am.  Gynaecol.  Soc,"  vol.  i,  p.  130. 
f  Jenks,  loc.  cit.,  p,  130. 


302 


THE  PATHOLOGY  OF  PREGNANCY. 


In  cases  of  ascertained  death  of  the  foetus,  and  in  those  of  inevi- 
table abortion,  all  measures  calculated  to  retard  the  emptying  of  the 
uterus  should  be  at  once  abandoned. 

In  the  first  four  months  there  are  no  unequivocal  signs  of  the  death 
of  the  foetus.  From  the  middle  of  pregnancy  onward,  death  may  be 
assumed  if,  after  repeated  examinations,  the  absence  of  the  fetal  heart- 
sounds  and  fetal  movements  is  confirmed. 

The  signs  of  inevitable  abortion  are  profuse  haemorrhage,  clots  dis- 
charged from  the  uterus,  dilatation  of  the  cervix  from  the  descent  of 
the  ovum,  and  a  patulous  condition  of  the  os  externum.  Other 
symptoms  consist  of  persistent  uterine  contractions,  escape  of  the 
amniotic  fluid,  and  the  presence  of  the  embryo,  or  of  portions  of  the 
ovum,  in  the  discharged  clots.  How  far  the  ordinary  signs  may,  in 
given  cases,  prove  delusive  is  shown  by  a  remarkable  one  reported  by 
Scanzoni,  of  a  woman  who  was  seized  with  profuse  metrorrhagia  in  the 
third  mouth  of  pregnancy.  Great  numbers  of  clots  were  discharged. 
As  all  hopes  of  saving  the  ovum  were  abandoned,  ergot  was  used  in 
large  doses,  a  tampon  was  placed  in  the  vagina  for  thirty-six  hours,  a 
sound  was  employed  to  explore  the  uterus,  and  finally,  as  the  bleeding 
continued  for  three  weeks,  an  intra-uterine  injection  of  a  weak  solu- 
tion of  perchloride  of  iron  was  resorted  to.  Eight  weeks  later  the 
patient  quickened,  and  presented  the  distinctive  evidences  of  a  preg- 
nancy advanced  to  the  sixth  month.* 

The  Treatment  of  Inevitable  Abortion. 

In  the  treatment  of  inevitable  abortion  it  is  proper  to  distinguish 
between  cases  of  abortion  proper  and  those  of  miscarriage.  To  avoid, 
however,  needless  repetitions,  it  is  only  points  of  distinctive  difference 
to  which  at  the  close  attention  will  be  directed.  The  management  of 
premature  deliveries  differs  in  no  respect  from  that  of  confinement  at 
term. 

In  the  first  two  months  little  treatment  besides  rest  in  bed  for  a 
few  days  is  ordinarily  required.  In  the  exceptional  cases,  the  treat- 
ment does  not  differ  from  that  in  the  haemorrhages  of  the  non-preg- 
nant uterus. 

In  the  third  month  we  distinguish — 1.  Cases  in  which  the  ovum 
is  thrown  off  entire  ;  2.  Cases  in  which  the  sac  ruptures,  and  the 
embryo  escapes  with  the  discharged  fluid. 

1.  When  in  the  third  month  the  ovum  is  thrown  off  Avithout 
rupture  of  the  fetal  membranes,  the  haemorrhage  rarely  assumes  dan- 
gerous proportions.  The  uterine  contractions  press  the  ovum  into 
the  cervix,  which  dilates  and,  in  primiparae,  becomes  somewhat  elon- 
gated. As  the  ovum  descends,  the  body  of  the  partially  emptied  ute- 
rus retracts.    The  effused  blood  coagulates  in  thin  layers  between  the 

*  Scanzoni,  "Lchibuch  dcr  Geburtshulfe,"  Wien,  1S67,  p.  83. 


THE  PREMATURE  EXPULSION  OF  THE  OVUM. 


303 


ovum  and  the  uterine  walls.  The  ovum,  forms  a  tampon,  which  fills 
the  cervix  and  restrains  the  haemorrhage. 

No  active  treatment  is,  therefore,  demanded.  A  vaginal  douche 
consisting  of  a  pint  of  tepid  water  may  be  used  twice  a  day  as  a  meas- 
ure of  cleanliness.  All  attempts  to  disengage  the  ovum  with  the 
finger  should  be  avoided,  as  endangering  its  integrity.  The  vaginal 
tampon  is  unnecessary.  It  should  only  be  used  as  a  safeguard,  where 
patients  live  at  a  distance  from  medical  assistance  and  can  only  be 
visited  at  long  intervals.  As  it  is  never  certain  that  the  rupture  of 
the  ovum  may  not  take  place  during  the  course  of  its  expulsion,  the 
tampon  may  in  such  cases  be  employed  in  anticipation  of  a  possible 
increase  of  haemorrhage  from  sudden  collapse  of  the  membranes.  In 
multiparae  the  ovum  seldom  remains  long  in  the  cervix.  In  primiparae, 
on  the  other  hand,  the  tardy  dilatation  of  the  os  externum  may  lead 
to  a  retention  of  the  ovum  in  the  cervix,  lasting  for  days.  As  this 
condition  is  extremely  painful,  it  is  allowable  to  dilate  the  os  exter- 
num with  the  index-finger,  or  even  by  incisions  through  the  ring  of 
circular  fibers  which  furnish  the  cause  of  delay. 

Small  portions  of  the  decidua  vera  sometimes  remain  attached  to 
the  uterine  walls  after  abortion.  They  commonly  do  no  harm,  but 
are  discharged  with  the  lochia}  secretion. 

2.  When  the  sac  ruptures,  and  the  liquor  amnii  escapes,  the  re- 
moval of  the  pressure  exerted  upon  the  uterine  wall  by  the  intact 
ovum  is  followed  by  profuse  haemorrhage  from  the  utero-placental 
vessels. 

The  diagnosis  of  rupture  may  be  made  either  from  finding  the 
embryo  in  the  clots,  or,  in  the  case  of  a  dilated  cervical  canal,  by  the 
direct  examination  of  the  uterine  cavity.  Although  after  rupture 
portions  of  the  ovum  may  still  be  felt,  Ave  miss  the  smooth  surface 
of  the  fluctuating  amniotic  sac.  When  the  embryo  can  not  be  found, 
and  the  cervix  is  closed,  profuse  haemorrhage  alone  would  render  the 
occurrence  of  rupture  extremely  probable. 

The  principles  of  treatment  in  these  cases  are  very  simple.  The 
indications  are,  to  check  the  haemorrhage  and  to  empty  the  uterus. 
As  to  the  best  methods  of  attaining  these  results,  opinions  widely 
differ. 

When  cases  are  treated  with  rest  in  bed,  the  internal  administration 
of  ergot,  and  cold  cloths  applied  to  the  abdomen  and  vulva,  the  loss  of 
blood  is  usually  considerable,  but  the  most  of  them  terminate  favor- 
ably. In  some,  however,  the  haemorrhage  may  prove  so  severe  as  even 
to  threaten  life.  Now,  it  is  in  every  way  desirable,  for  the  future  wel- 
fare of  the  patient,  to  restrain  the  haemorrhage  within  the  narrowest 
limits.  The  most  effectual  means  of  arresting  the  haemorrhage  is  to 
clean  out  the  uterus.  If,  therefore,  the  physician  at  the  time  of  his 
visit  finds  the  cervix  sufficiently  dilated  to  allow  him  to  introduce  his 


304 


THE  PATHOLOGY  OF  PREGNANCY. 


finger  into  the  uterus,  he  should  not  hesitate  at  once  to  remove  the 
retained  portions  of  ovum.  The  operation  does  not  require  any  con- 
siderable amount  of  technical  skill,  while  the  immediate  results  are 
in  the  highest  degree  satisfactory.  The  patient  should  be  placed  cross- 
wise in  bed,  with  the  hips  drawn  well  over  the  edge.  The  legs  should 
be  flexed  and  the  thighs  held,  where  assistants  can  be  obtained,  at 
right  angles  to  the  body,  to  secure  the  greatest  degree  of  relaxation  to 
the  perinaBum  and  abdominal  walls.  The  right  index-finger  should  be 
then  passed  into  the  vagina  and  through  the  cervical  canal,  while  the 
left  hand,  placed  upon  the  abdomen,  gradually  presses  the  uterus  down 
into  the  pelvic  cavity  so  as  to  bring  it  within  reach  of  the  examining 
finger.*  This  portion  of  the  act  should  be  performed  slowly,  while 
every  effort  is  made  to  divert  the  attention  of  the  patient.  Hasty 
manipulations  invariably  excite  in  the  most  willing  of  patients  the 
full  resistance  of  the  abdominal  walls.  When  the  point  of  the  finger 
reaches  the  os  internum,  it  is  sometimes  necessary  to  pause  for  a  minute 
or  two,  to  await  a  sufficient  degree  of  dilatation  to  allow  the  finger  to 
pass  beyond  the  insertion  of  the  nail.  When  the  right  finger  is  used, 
it  should  be  made  to  pass  upward  with  its  dorsal  surface  along  the  left 
side  of  the  uterus  to  the  opening  of  the  Fallopian  tube,  thence  across 
the  fundus  to  the  right  side.  As  the  tip  of  the  finger  passes  down 
upon  the  right  side,  it  presses  the  detached  ovum  before  it  toward  the 
OS  internum.  By  the  time  the  finger  has  thus  made  the  circuit  of 
the  uterus,  the  ovum  is  pressed  into  the  cervical  canal,  and  thence 
passes  easily  into  the  vagina.  With  the  left  finger,  the  movement  is 
exactly  the  reverse.  The  finger  passes  first,  with  its  dorsal  surface 
directed  to  the  right  side,  from  the  right  Fallopian  tube  across  the  fun- 
dus, and  downward  along  the  left  side  of  the  uterus.  The  only  resist- 
ance the  finger  meets  is  at  the  placental  insertion,  where  a  certain 
amount  of  manipulation  is  required  to  complete  the  detachment,  f 

Where  the  uterus  can  not  be  pressed  down  within  reach  of  the 
index-finger  by  force  exerted  above  the  symphysis  pubis,  it  is  permis- 
sible to  introduce  the  hand  into  the  vagina  ;  but,  in  such  a  case,  the 
fingers  are  apt  to  become  cramped,  and  all  freedom  of  manipulation 
to  be  destroyed.  A  better  means  of  overcoming  the  difficulty  consists 
in  the  administration  of  an  anaesthetic.  In  cases  of  extreme  anaemia 
chloroform  should  be  discarded  as  too  dangerous.  Ether,  however, 
has  often  seemed  to  me,  on  the  contrary,  to  possess  a  stimulating  action, 
and  its  use  to  be  followed  by  increase  in  the  volume  and  force  of  the 

*  Professor  A.  R.  Simpson  ("Transactions  of  the  Elinburqh  Obstetrical  Society,"  vol. 
iv,  p.  227)  recommends  drawing  down  the  uterus  by  means  of  volscllum-forceps  attached 
to  the  anterior  lip  of  the  cervix.  I  have  once  seen  extreme  haemorrhage  follow  this  ma- 
noeuvre (seventh  month  of  pregnancy),  and  now  feel  some  hesitation  about  its  employ- 
ment, at  least  in  the  later  months. 

f  Vide  HiiTER,  "  Compendium  der  geburtshiilflichcn  Operationcn,"  p.  22. 


THE  Prx,EMATURE  EXPULSION  OF  TIJE  OVUM. 


305 


pulse.  The  relaxation  produced  by  the  anaesthetic  makes  it  easy  to 
depress  the  uterus  down  to  the  pelvic  floor,  where  it  can  be  reached 
with  comparative  ease.  After  the  removal  of  the  ovum,  the  cavity  of 
the  uterus  should  be  washed  out  with  a  stream  of  tepid  carbolized 
water,  in  order  to  bring  away  any  small  detached  portions  of  the  ovum 
and  decidua.  In  the  manual  extraction  of  the  ovum,  deliberation 
and  perseverance  are  the  main  elements  of  success. 

If,  when  the  patient  is  first  seen  by  the  physician,  the  cervix  is  not 
sufficiently  dilated  to  allow  the  finger  to  pass  without  force,  the  vagi- 
nal tampon  should  be  employed.  The  tampon  restrains  the  haemor- 
rhage, stimulates  the  uterus  to  contraction,  and  allows  time  for  the 
employment  of  measures  to  rally  a  patient  exhausted  by  profuse  losses 
of  blood.  The  material  of  which  a  tampon  is  made  is  a  matter  of  in- 
difference, provided  only  it  fills  the  vagina  to  its  utmost  capacity. 
In  cases  of  urgent  need,  a  soft  towel,  handkerchiefs,  strips  of  cotton 
cloth,  dampened  cotton-wool,  and  the  like,  may  be  seized  upon  to 
meet  a  temporary  emergency.  The  time-honored  sponge,  on  account 
of  its  porosity,  is  least  deserving  of  favor.  When,  however,  the  phy- 
sician proposes  to  leave  his  patient  for  a  number  of  hours,  the  mere 
hasty  filling  of  the  vagina  through  the  vulva  will  not  suffice.  On 
the  contrary,  the  highest  degree  of  safety  can  only  be  secured  by  the 
closest  observance  of  the  rules  of  art. 

The  first  essential  of  a  good  tampon  is  that  it  be  carefully  packed 
around  the  cervix  uteri,  and  fill  out  the  more  dilatable  upper  portion 
of  the  vagina.  This  can  be  accomplished  only  by  the  aid  of  a  specu- 
lum. The  method  I  usually  employ  is  one,  the  credit  of  which,  so  far 
as  the  general  features  are  concerned,  I  believe  belongs  to  Dr.  Marion 
Sims.  It  consists  in  soaking  cotton-wool  in  carbolized  water,  and 
then,  after  pressing  out  any  excess  of  fluid,  in  forming  from  the  carbo- 
lized cotton  a  number  of  flattened  disks  of  about  the  size  of  the  trade- 
dollar.  The  patient  is  then  placed  in  the  latero-prone  position,  and 
the  perinaeum  retracted  by  a  Sims's  speculum.  The  dampened  cotton 
disks  are  introduced  by  dressing-forceps,  and,  under  the  guidance  of  the 
eye,  are  packed  first  around  the  vaginal  portion,  then  over  the  os,  and 
thence  the  vagina  is  filled  in  from  above  downward  until  the  narrow 
portion  above  the  vestibule  is  reached.  No  other  plan  of  tamponing 
with  which  I  am  acquainted  can  compare  in  solidity  and  effectiveness 
with  this.  Its  removal  is  accomplished  by  the  detachment  with  two 
fingers  of  a  portion  at  a  time.  This  part  of  the  procedure  is  moder- 
ately painful.  Many  methods  have  been  suggested  to  overcome  in  the 
removal  the  necessity  of  introducing  the  finger  into  the  vagina.  A 
very  ingenious  one  consists  in  attachmg  the  cotton  to  a  piece  of  twine 
so  as  to  form  a  kite-tail,  which  can  be  withdrawn  by  simply  making 
tractions  upon  the  extremity  of  the  string  left  hanging  outside  the 
vulva.  Professor  I.  E.  Taylor  uses  a  roller-bandage.  It  is  efficient, 
20 


306 


THE  PATHOLOGY  OF  PREGNANCY. 


and,  like  the  kite-tail  described,  can  be  easily  removed.  Dr.  F.  P. 
Foster*  advises  the  use  of  the  lamp-wicking  as  a  material  for  the 
tampon. 

Before  the  introduction  of  the  tampon,  the  vagina  should  be  thor- 
oughly washed  out.  No  tampon  should  be  allowed  to  remain  in  the 
vagina  much  over  twelve  hours.  Immediately  after  withdrawing  the 
tampon,  before  proceeding  to  the  examination  of  the  uterus,  the  vagi- 
na should  be  cleansed  by  an  injection  of  tepid  carbolized  water  (gr. 
XXX  ad  Oj).  Often,  after  removing  the  tampon,  the  ovum  is  found 
in  the  upper  portion  of  the  vagina  or  filling  up  the  cervix.  If  this  is 
not  the  case,  and  the  cervix  is  not  dilated,  so  that  manual  extraction 
may  easily  be  performed,  another  tampon  should  be  introduced. 

It  is  customary  from  the  outset  to  sustain  the  action  of  the  tampon 
by  the  administration  of  ergot,  either  in  the  form  of  the  fluid  extract 
(thirty  drops  every  three  to  four  hours),  or  of  a  solution  of  ergo  tin, 
given  hypodermically  (ergotin,  gr.  xij,  glycerinae,  3  j.  Ten  minims 
twice  in  the  twenty-four  hours.  In  women  with  abundant  adipose 
tissue  the  injection  should  be  made  into  the  subcutaneous  tissues  of 
the  lower  abdomen.  In  others,  the  outer  surface  of  the  thigh  should 
be  selected). 

If  the  patient  is  collapsed  from  loss  of  blood  after  tamponing,  opi- 
ates, tea,  and  alcoholic  stimulants  should  be  administered,  the  latter 
in  small  but  frequently  repeated  quantities,  until  the  cerebral  anaemia 
is  relieved  and  the  capillary  circulation  restored. 

If,  after  the  removal,  the  cervix  is  found  not  to  be  dilated,  a  third 
tampon  may  be  introduced,  and  left  in  situ  for  another  period  of 
twelve  hours.  The  employment  of  the  tampon  is  not,  however,  to  be 
recommended  for  a  period  much  exceeding  twenty-four  hours.  Its 
continued  use  is  apt  to  irritate  the  vagina.  In  spite  of  carbolic  acid, 
it  acquires  an  offensive  odor.  It  generates  septic  matters,  which,  in  the 
long-run,  creep  upward  through  the  cervix  into  the  uterine  cavity, 
and  produce  decomposition  of  the  ovum.  I  prefer,  therefore,  in  cases 
of  undilated  cervix,  after  twenty-four  hours  of  vaginal  tamponing,  to 
resort  to  sponge-tents.  The  sponge-tent  is  most  easily  introduced 
when  the  patient  is  placed  upon  her  left  side,  with  the  perinaeum  drawn 
back  by  Sims's  speculum,  and  the  anterior  lip  of  the  cervix  drawn 
down  and  steadied  by  a  tenaculum  (Sims's  method).  The  tent  may, 
however,  in  the  absence  of  an  assistant,  be  introduced,  with  the  patient 
on  her  back,  by  the  aid  of  a  pair  of  strong  dressing-forceps.  The  tent 
should  be  long  enough  to  pass  well  up  through  the  os  internum. 
Within  six  to  twelve  hours  the  tent  should  be  removed,  and,  after  a 
preliminary  vaginal  douche,  manual  extraction  be  proceeded  with  in 
accordance  with  the  rules  already  given. 

In  manual  delivery,  it  is  desirable  to  remove  the  decidua  as  well  as 

*  Foster,  "  N.  Y.  Med.  Jour.,"  June,  1880. 


THE  PREMATURE  EXPULSION  OF  THE  OVUM. 


307 


the  OYnm.  When  the  cervix  is  patent,  this  is  easy,  as  the  decidua  is 
then  detached  from  the  uterine  walls.  When  the  cervix  is  unchanged, 
the  detachment  is  usually  incomplete.  In  such  cases,  it  is  advisa- 
ble, therefore,  to  try  first  the  tampon  before  the  sponge-tent,  as  the 
former  stimulates  the  uterus  to  contract,  and  promotes  the  separa- 
tion of  the  decidua,  even  when  it  fails  to  secure  the  discharge  of  the 
ovum. 

Inside  the  uterine  cavity,  ovum-f orceins  should  be  used  with  great 
caution.  I  have  discarded  it  altogether.  In  the  first  place,  it  is 
dangerous  ;  in  the  second  place,  it  is  unnecessary.  When,  however, 
the  retained  portions  of  the  ovum  have  left  for  the  most  part  the 
uterine  cavity,  and  occupy  the  cervical  canal,  the  delivery  may  at 
times  be  advantageously  hastened  by  placing  the  patient  upon  her 
side,  and,  with  the  cervix  well  brought  into  view  by  a  Sims's  spec- 
ulum, applying  the  ovum-forceps,  under  the  guidance  of  the  eye, 
within  the  cervix  to  the  sides  of  the  placenta  (Skene).  But  great  care 
requires  to  be  exercised  not  to  break  away  the  fragile  structures  and 
leave  material  portions  behind. 

Under  like  circumstances,  Hoening  *  recommended  a  modification 
of  Crede's  method  for  expression  of  the  placenta.  With  the  patient 
lying  upon  the  back,  the  operator,  according  to  Hoening,  should  seek 
to  compress  the  body  of  the  uterus  between  the  left  hand,  laid  above 
the  symphysis  pubis,  and  two  fingers  of  the  right  hand  introduced  into 
the  vagina.  The  measure  is  only  practicable  when  the  ovum  has,  to  a 
great  extent,  passed  from  the  uterine  cavity.  As  it  is  somewhat  pain- 
ful, and  requires  for  success  lax  abdominal  parietes,  it  possesses  a  lim- 
ited range  of  applicability. 

Treatment  of  Neglected  Abortion. — Where,  following  abortion,  the 
uterus  has  once  been  completely  evacuated,  haemorrhage  ceases.  A 
slight  lochial  discharge  persists  for  a  few  days  during  the  period  in 
which  the  uterine  portion  of  the  decidua  vera  completes  its  period  of 
repair.  If,  therefore,  a  patient  comes  to  us  two  or  three  weeks  after 
the  supposed  conclusion  of  an  abortion,  with  the  story  of  recurrent 
haemorrhages  taking  place,  as  a  rule,  whenever  she  leaves  her  bed  and 
assumes  the  upright  position,  it  may  be  assumed,  with  an  approach  to 
certainty,  that  portions  of  the  ovum  still  remain  within  the  uterus. 
Oftentimes  a  fetid  discharge  points  to  the  fact  that  decomposition  has 
been  set  up.  The  absorption  of  septic  materials  may,  furthermore, 
become  the  sourpe  of  chills,  of  fever,  and  of  great  uterine  tenderness. 
In  most  cases,  with  rest  in  bed,  the  contents  are  discharged  by  sup- 
13uration,  and  recovery  ultimately  takes  place,  but  only  after  a  slow, 
protracted  convalescence,  during  which  pelvic  cellulitis  and  pelvic 
peritonitis  occur  as  not  uncommon  complications.  Haemorrhages, 
peritonitis,  and  septicaemia  may,  however,  bring  the  case  to  a  fatal 
*  Hoening,  Scanzoni's  "  Beitrage,"  Bd.  vii,  p.  213. 


308 


THE  PATHOLOGY  OF  PREGNANCY. 


issue.  The  removal  of  the  retained  placenta  and  membranes  is  there- 
fore indicated,  not  only  as  a  measure  calculated  to  promote  recovery, 
but  to  avert  possible  danger  to  life. 

With  regard  to  the  operation  for  removal,  the  rules  already  given 
are  applicable.  The  following  peculiarities  should,  however,  be  borne 
in  mind.  In  case  the  retained  portions  are  undecomposed,  the  cervix 
is  usually  found  closed,  and  requires  preliminary  dilatation  with  the 
sponge-tent.  When  decomposition  has  once  set  in,  the  os  internum 
will,  as  a  rule,  allow  the  finger  to  j)ass  into  the  uterus.*  When  a 
decomposed  ovum  is  removed  by  the  finger,  a  chill  and  a  septic  fever, 
which  rapidly  disappear,  however,  are  apt  to  follow  in  the  course  of 
a  few  hours.  This  chill  and  fever  result  from  the  slight  traumatic 
injuries  inflicted  by  the  finger  upon  the  uterine  walls,  whereby  the 
capillaries  and  lymphatics  become  opened  up  to  the  action  of  the  sep- 
tic poisons.  The  fever  ends  in  a  short  time,  because  the  reservoir  of 
supply  is  removed  with  the  debris  of  the  ovum.  If  the  uterine  cavity, 
after  the  operation,  is  carefully  washed  out  with  carbolized  water, 
the  septic  fever  is  often  averted.  The  beneficial  results  following  the 
complete  emptying  of  the  uterus  in  these  cases  are  so  decided,  that  of 
late  years  I  have  not  allowed  myself  to  be  deterred  from  proceeding 
actively,  even  when  perimetritis  and  parametritis,  in  not  too  acute  a 
form,  already  existed.  In  practice,  multitudes  of  examples  show  that 
the  products  of  inflammations  situated  in  the  pelvis  do  not  become 
absorbed  so  long  as  putrid  materials  are  generated  in  the  uterine 
cavity. 

The  removal  of  a  fibrinous  polypus,  owing  to  its  smoothness  and 
the  small  size  of  the  pedicle,  is  often  a  Sisyphus's  task.  The  separation 
can  only  be  successfully  accomplished  when  the  palmar  surface  of  the 
index-finger  presses  from  above  upon  the  point  of  attachment.  This 
necessitates  a  choice  of  hands.  Thus,  when  the  polypus  is  situated 
to  the  left,  the  right  index-finger  should  be  employed,  and  the  left 
index-finger,  when  the  polypus  is  situated  to  the  right.  After  the 
detachment  is  complete,  it  is  necessary  to  press  the  polypoid  body 
firmly  against  the  uterine  walls,  and  proceed  with  its  withdrawal 
slowly.  If,  as  is  sometimes  the  case,  the  polypus  slips  from  under  the 
finger,  the  latter  should  be  again  passed  to  the  fundus  of  the  uterus, 
and  the  attempt  repeated.  Small  portions,  not  larger  than  a  pea,  can 
be  washed  out  by  the  uterine  douche.  When  the  polypus  is  situated 
near  the  os  internum,  the  latter  will  be  found  patulous,  but,  when  it  is 
well  up  within  the  body  of  the  uterus,  dilatation  is  a  frequent  prerequi- 
site to  removal. 

For  the  removal  of  presumably  small  portions  of  retained  ovum, 
especially  in  cases  where,  owing  to  inflammatory  conditions,  I  have 
hesitated  to  make  the  circuit  of  the  uterine  cavity  with  my  finger, 

*  HuTKK,  "  Compendium  der  gebhulflichen  Opcrationen,"  Leipsic,  ISV-l,  p.  32. 


EXTRA-UTERINE  PREGNANCY. 


309 


I  have  succeeded  admirably  by  employing  a  tolerably  firm  Thomas's 
wire  curette.  * 

The  Treatment  of  Immature  Deliveries. — Fourth  to  seventli  month. 
— Distinctive  of  immature  deliveries  are  :  painful  periodic  contrac- 
tions, recognizable  by  the  hand  applied  above  the  symphysis  pubis, 
rupture  of  the  membranes  and  discharge  of  the  foetus,  the  complete 
formation  of  the  placenta  and  umbilical  cord  ;  while  in  abortion  the 
uterine  contractions  are  obscure,  the  placenta  is  rudimentary,  and  the 
ovum  is  frequently  expelled  entire.  In  the  treatment  of  immature 
delivery,  the  tampon  may  usually  be  discarded.  After  rupture  of  the 
membranes  and  expulsion  of  the  foetus,  the  haemorrhage  should  be 
controlled  by  grasping  the  fundus  of  the  uterus  in  the  hand  through 
the  abdomen,  and  compressing  the  uterine  walls  firmly  together. 

The  passage  of  the  foetus  opens  the  uterus  so  as  to  allow,  in  the 
fourth  and  fifth  months,  the  introduction  of  two  fingers  ;  in  the  sixth 
and  seventh  months,  that  of  the  half-hand.  In  case  compression  of 
the  uterus  does  not  arrest  the  haemorrhage  and  expel  the  placenta,  the 
cord  should  be  carefully  followed  to  its  insertion,  to  determine  the 
side  upon  which  the  implantation  exists.  If  the  placenta  is  implanted 
upon  the  right  side,  two  or  four  fingers  of  the  right  hand,  according 
to  the  degree  of  cervical  dilatation,  should  be  passed  up  along  the  left 
side  of  the  uterus,  across  the  fundus  to  the  placental  site.  The  de- 
tachment should  be  effected  with  the  tips  of  the  fingers,  and  the  pla- 
centa pressed  downward  as  the  fingers  descend  along  the  right  side  of 
the  uterus.  The  left  hand  should  be  employed  in  the  reverse  direc- 
tion, when  the  placenta  is  situated  to  the  right. 


CHAPTER  XVII. 

EXTRA-UTERINE  PREGNANCY. 

Definition. — Tubal  pregnancy. — Pregnancy  in  rudimentary  cornu. — Interstitial  pregnancy. 
— Tubo-abdominal  and  tubo-ovarian  pregnancy. — Ovarian  pregnancy. — Abdominal 
pregnancy. —  Symptoms. —  Terminations. —  Diagnosis. — Treatment,  in  cases  of  early 
gestation. — Cases  of  advanced  gestation  (foetus  living), — Cases  of  gestation  pro- 
longed after  the  death  of  the  foetus. 

After  coitus,  the  spermatozoa  make  their  way  through  the  Fallo- 
pian tubes  to  the  pelvic  cavity.  It  is  possible,  therefore,  for  the  ovum 
to  become  fecundated  in  any  portion  of  the  route  from  the  ovary  to 

♦Skene,  "  Med.  Record,"  1875,  p.  59;  Munde,  "  Centralbl.  f.  Gynaek.,"  1878,  No. 
vi,  p.  1.  The  patient  should  be  placed  in  Sims's  position,  the  perinjBum  should  be  drawn 
back  with  Sims's  speculum,  the  cervix  hooked  down  and  steadied  with  a  tenaculum,  while 
the  curette  is  made  to  pass  over  all  portions  of  the  uterine  surface.  Attached  bits  of 
placenta  are  recognized  by  the  resistance  they  offer. 


310 


THE  PATHOLOGY  OF  PREGNANCY. 


the  uterus.  In  exceptional  cases,  the  ovum  may,  after  fecundation,  be 
arrested  in  its  travels,  and  undergo  development  at  some  point  outside 
of  the  uterus.  To  these  fortunately  rare  cases  the  term  extra-uterine 
pregnancy  has  been  applied. 

The  terms  tubal,  ovarian,  and  abdominal  pregnancy  designate 
different  forms  of  extra-uterine  development,  and  serve  to  express 
the  site  of  the  attachment  from  which  the  growth  of  the  ovum  be- 
gins. 

Tubal  Pregnancy. — Tubal  pregnancy  is  the  most  frequent  of  the 
three  forms.  The  ovum  may  find  lodgment  in  any  part  of  the  tube. 
The  causes  of  this  anomaly  are  to  be  sought  for  in  catarrhal  aifections 
attended  with  loss  of  the  ciliated  epithelium,  dilatation,  and,  in  some 
cases,  with  the  formation  of  hernial  pouches,  produced  by  the  protru- 
sion of  the  mucous  membrane  through  separated  bundles  of  the  mus- 
cular fibers  ;  or  the  ovum  may  be  arrested  by  flexions  and  constrictions 
of  the  tube  resulting  from  adhesions  and  old  inflammatory  bands. 
In  a  few  instances  a  small  polypus  has  been  found  filling  up  the  caliber 
of  the  tube.  Because  of  its  connection  with  inflammatory  processes, 
the  occurrence  of  tubal  pregnancy  is  often  preceded  by  a  long  period 
of  sterility.  When  the  obliteration  is  only  partial,  the  spermatozoa, 
owing  to  their  small  size,  are  not  prevented  from  reaching  the  arrested 
ovum  ;  when  complete,  on  the  contrary,  they  can  only  gain  access  to 
the  ovum  by  first  passing  through  the  patulous  tube,  and  then  migrat- 
ing across  the  rear  of  the  uterus  to  the  ovary  or  the  open  abdominal 
end  of  the  tube  upon  the  opposite  side.  In  a  considerable  number 
of  cases,  the  corpus  luteum  has  been  found  upon  the  side  oj)posite  to 
the  tube  containing  the  fecundated  ovum.  With  the  present  pre- 
vailing views,*  this  phenomenon  is  only  to  be  accounted  for  by 
the  hypothesis  of  the  migration  of  the  ovum  across  the  peritoneal 
surface  of  the  pelvis  or  through  the  uterus  from  one  tube  to  the 
other. 

As  the  ovum  develops,  the  mucous  membrane  of  the  tube  thickens 
after  the  manner  of  the  decidua,  and  receives  the  club-shaped  extrem- 
ities of  the  villi.  Until  the  formation  of  the  placenta,  the  detachment 
of  the  ovum  is  easy.  Usually  the  two  poles  of  the  decidua-like  cover- 
ing are  closed,  though  sometimes  the  uterine  end  remains  open,  and 
in  continuity  with  the  mucous  membrane  of  the  tube  and  the  decidua 
of  the  uterine  cavity,  f    A  decidua  reflexa  is  in  any  event  extremely 

*  Mayrhofer,  "  Ueber  die  gclben  Korper,  und  die  Ueberwanderung  des  Eies,"  denies 
the  whole  doctrine  of  a  distinct  corpus  luteum  of  pregnancy,  and  claims  that  corpora  lutea 
are  found  at  stated  intervals,  perhaps  monthly,  throughout  the  entire  period  of  preg- 
nancy. Leopold,  "  Die  Ueberwanderung  der  Eier,"  "Arch.  f.  Gynaek.,"  Bd.  xvi,  p.  24, 
however,  found  that  after  tying  the  right  tube  and  after  removing  the  entire  left  ovary 
in  a  couple  of  rabbits  pregnancy  still  took  place. 

f  L.  Bandl,  Billroth's  "  Handbuch  der  Frauenkrankheiten,"  5te  Abschn.,  art.  "  Extra- 
uterinschwangerschaft,"  p.  44. 


EXTRA-UTERINE  PREGNANCY. 


311 


rare.*  The  placenta  is  purely  a  fetal  organ.  The  villi  penetrate  to  the 
muscular  structures  of  the  tube,  where  they  are  occasionally  surround- 
ed by  large  vessels.  Nowhere,  however,  have  they  been  observed  to 
have  broken  through  the  walls  of  the  maternal  vessels,  nor  is  there 
any  evidence  of  maternal  blood  in  the  intervillous  spaces,  such  as  is 
believed  to  exist  in  cases  of  intra-uterine  development,  f 

With  the  beginning  of  pregnancy  the  muscular  walls  of  the  tube 
hypertrophy,  but  they  subsequently  are  stretched  thin  by  the  growth 


Fig.  143. — Tubal  pregnancy.    (N.  Sommer.) 


of  the  ovum.  At  an  early  period,  usually  within  the  first  three 
months,  rupture  of  the  sac  occurs  at  the  point  of  least  resistance, 
which  corresponds  in  many  cases  to  the  site  of  the  placenta.  With 
rare  exceptions  death  follows  rupture,  either  immediately  from  acute 
internal  haemorrhage,  or  secondarily  from  peritonitis. 

Rupture  of  the  tube-walls  may  be  associated  with  rupture  of  the 
ovum  and  escape  of  the  foetus  into  the  abdominal  cavity,  or  the  ovum 
may  pass  intact  into  the  peritonaeum  ;  or,  finally  (and  this  is  the  more 
favorable  termination),  the  ovum  may  remain  in  the  tube,  where  it  can 
serve  as  a  tampon  and  diminish  the  extent  of  the  haemorrhage. 

Recovery  may  occur  in  case  of  premature  death  of  the  embryo 
before  rupture  takes  place  ;  or  subsequent  to  rupture,  by  the  forma- 
tion of  false  membranes  around  the  embryo,  or  the  entire  ovum. 

Exceptionally  tubal  pregnancy  may,  owing  to  an  extraordinary 
thickening  of  the  muscular  walls,  advance  to  full  term.  Spiegelberg 
refers  to  three  instances  of  the  kind — one  reported  by  Saxtorph,  one 

*  Hennig  found  in  one  hundred  and  fifty  reported  cases  a  reflcxa  mentioned  in  but 
five  ("Die  Krankheiten  der  Eileitera  und  die  Tubcnschwangerschaft,"  p.  150). 

f  Vide  CosRAD  und  Langhaus,  " Tubenscliwangerschaft,"  "Arch.  f.  Gynaek,"  Bd. 
ix,  p.  358 ;  also  Leopold,  "  Tubenschwangerschaft,"  etc.,  ibid.,  Bd.  x,  p.  262. 


\ 


312 


THE  PATHOLOGY  OF  PREGNANCY. 


by  himself,  and  one  by  Fabbri.*  Hofmeier  f  likewise  reports  a  case  of 
probably  the  same  character 4 

Eupture  of  the  tube  may  occur  in  the  portion  not  covered  by  the 
peritonaeum.    Blood  is  then  effused  between  the  folds  of  the  broad 


Fig.  144.— Pregnancy  in  rudimentary  comu.  (Kussmaul,  observed  by  Heyfelder.) 


ligament,  and  into  the  cavity  thus  formed  the  ovum  may  escape.  This 
form  is  known  as  extra-peritoneal  pregnancy. 

Pregnancy  in  the  Rudimentary  Cornu  of  a  One-horned  Uterus. — 
This  anomaly  so  closely  resembles  the  tubal  form  of  pregnancy  that 
the  diagnostic  distinction  can  rarely  be  established  during  life.  Even 
after  death  the  only  certain  guide  is  furnished  by  the  situation  of  the 
round  ligament,  which  in  the  rudimentary  horn  is  found  external  to 
the  sac,  while  in  tubal  pregnancy  it  lies  between  the  sac  and  the 
uterus.  In  tubal  pregnancy,  however,  rupture  takes  place,  as  a  rule, 
during  the  first  three  months,  while  the  rupture  of  the  cornu  occurs 

*  Spiegelberg,  "  Lehrbuch  der  Geburtshiilfe,"  p.  312. 

f  Hofmeier,  "  Ztschr.  f.  Geburtsh.  und  Gynack.,"  Bd.  v,  p.  115. 

:|:  Ernst  Frankel  ("Arch.  f.  Gynaek.,"  Bd.  xiv,  p.  205)  collected  twenty-six  cases,  occur- 
ring between  1875  and  1879,  of  pure  tubal  pregnancy,  in  which  the  diagnosis  was  con- 
finned  by  subsequent  post  mortem  examination.  Of  these  but  seventeen  terminated  in 
rupture  during  the  first  three  months.  Of  the  remaining  nine,  two  reached  full  term 
(Simpson's  and  Tinker's),  one  completed  eight  months  of  gestation  (Cullingwcrth's),  one 
six  months  (Bollinger's),  one  five  months  (Netzel's  and  Bliek's),  and  two  four  months 
(Frankel's  and  Netzel's). 


EXTRA-UTERINE  PREGNANCY. 


313 


somewhat  later,  usually  between  the  third  and  sixth  month.  In  one 
ease,  related  by  Turner,*  pregnancy  went  on  to  full  term  ;  the  i:)atient 
dying  of  phthisis  six  months  after  labor,  the  dead  child  was  found  in 
the  left  cornu.  Eupture  takes  place  at  the  apex  of  the  cornu,  where 
the  tenuity  of  the  walls  is  most  pronounced.  Koeberle  f  mentions  a 
case  where  the  child  died  in  the  fifth  month,  and  was  converted  into 
a  lithopaedion. 

Interstitial  Pregnancy. — The  term  interstitial  pregnancy  is  applied 
to  cases  in  which  the  ovum  is  developed  in  the  uterine  portion  of  the 
tube.  The  latter  measures  about  seven  lines  in  length  by  one  line  in 
diameter.  At  first  the  muscular  walls  hypertrophy  and  form  around 
the  ovum  a  sac  which  projects  from  the  upper  angle  of  the  uterus. 
As,  ordinarily,  the  growth  of  the  muscular  tissue  does  not  keep  pace 
with  that  of  the  ovum,  rupture  occurs  at  an  early  period,  usually  be- 
fore the  fourth  month.    Rokitansky,^:  however,  cites  a  case  in  which 


Fig.  145. — Interstitial  pregnancy.  (Hcnnig.) 

the  thickened  muscular  walls  resisted  the  pressure  of  the  ovum  to  the 
end  of  gestation,  the  child  having  been  removed  by  laparotomy  in  the 
tenth  month. 

When  the  ovum  develops  in  the  outer  end  of  the  uterine  portion,  it 

*  Turner,  "Edinburgh  Med.  Jour.,"  May,  1866,  p.  9'74. 

f  KffiBERLE,  "Gaz.  Hcbd.,"  1866,  No.  34. 

X  Vide  SriEGELBEno,  "  Lehrbucb  dcr  Geburtshulfc,"  p.  313. 


314  THE  PATHOLOGY  OF  PREGNANCY. 

may  grow  partly  outward  into  the  tube.  This  form  is  termed  tubo- 
interstitial  pregnancy.  On  the  other  hand,  when  near  the  inner  ex- 
tremity, the  ovum  may  dilate  the  ostium  and  pass  into  the  uterine 
cavity,  and  be  expelled  after  the  manner  of  an  ordinary  abortion.* 
Another  possible  form  of  interstitial  pregnancy  is  furnished  by  the 
occasional  existence  of  a  canal,  open  at  its  two  extremities,  and  appar- 
ently a  continuation  or  a  bifurcation  of  the  Fallopian  tube.  A  case 
reported  by  Dr.  Gilbert,  in  the  ''Boston  Medical  and  Surgical  Jour- 
nal" (March  3,  1877),  where  the  head  of  the  child  could  be  felt  just 
above  the  os  internum,  covered  by  a  thin  mucous  membrane,  and  in 
which  delivery  was  successfully  accomplished  by  an  incision  through 
the  partition,  probably  belonged  to  this  variety.    A  similar  case,  in 


Fig.  146. — Bifurcation  of  tubal  canal.  (Hcnnig.) 


the  practice  of  Dr.  H.  Lenox  Hodge,  is  reported  by  Parry  {op.  cit.,  p. 
266). 

In  the  post-mortem  examinations  the  distinction  between  an  inter- 
stitial pregnancy  and  one  in  a  rudimentary  cornu  is  not  easy  to  make 
out,  as  in  both  the  round  ligament  lies  to  the  outer  side  of  the  tumor. 
The  chief  points  of  difference  consist  in  the  fact  that  in  interstitial 
pregnancy  the  sac  is  separated  from  the  uterus  by  a  partition,  while 
in  pregnancy  in  a  rudimentary  cornu  the  two  halves  of  the  uterus 
are  united  by  a  muscular  band,  which  is  situated,  not  at  the  upper 
angle,  but  near  the  os  internum,  f 

Tubo-Abdominal  and  Tubo-Ovarian  Pregnancy. — When  the  ovum 
becomes  lodged  near  the  trumpet-shaped  extremity  of  the  Fallopian 
tube  it  grows  outward  into  the  abdominal  cavity.  Local  peritonitis  is 
then  set  up,  and  plastic  exudation  is  thrown  out,  forming  an  envelope 

*  In  this  category  we  should  certainly  place  the  case  of  Dr.  Charles  McBurney  ("New- 
York  Med.  Jour.,"  March,  1878,  p.  273)  and  that  of  Dr.  Cornelius  Williams,  in  the 
December  number  of  the  same  journal  (p.  595),  both  of  which  were  followed  by  the  recov- 
ery of  the  mother. 

f  Spiegelberg,  "Lchrbuch  der  Gcburtshiilfe,"  p.  315. 


EXTRA-UTEEINE  PREGNANCY. 


315 


around  the  ovum,  which  is  likewise  bounded  by  the  contiguous  or- 
gans. In  this  way  the  ligamenta  lata,  the  ovaries,  the  mesentery,  the 
intestines,  the  bladder,  and  the  uterus,  may  all  contribute  to  the 
investment  of  the  fetal  membranes.  In  case  of  rupture  in  the  tubal 
portion,  inflammatory  products  may  form,  and  limit  the  extent  of 
the  injury.  At  first,  owing  to  its  weight,  the  distended  tube  drops 
into  the  cul-de-sac  of  Douglas.  In  advanced  pregnancy,  the  spleen, 
kidneys,  and  liver  may  become  involved,  and  form  part  of  the  sac- 
walls  around  the  ovum.  Usually  the  placenta  is  developed  in  the 
pelvic  cavity.* 

When  the  investment  of  the  ovum  is  furnished  by  the  tube  and 
the  ovary,  the  term  tubo-ovarian  pregnancy  is  employed.  The  course 
in  either  case  does  not  materially  differ  from  that  of  an  abdominal 
pregnancy. 

Ovarian  Pregnancy. — A  number  of  well-observed  cases  are  now  on 
record  f  where  the  fecundation  and  development  of  the  ovum  have 
taken  place  within  the  Graafian  follicle,  the  walls  of  the  latter  and 
the  ovarian  stroma  furnishing  to  the  growing  ovum,  in  whole  or  in 
part,  a  membranous  envelojoe,  like  the  wall  of  an  ovarian  cyst. 
Subsequent  to  fecundation  the  Graafian  follicle  may  close,  and  the 
ovum  continue  extra-peritoneal,  or  the  ovum  may  gradually  make  its 
way  through  the  opening  occasioned  by  the  escape  of  the  Graafian 
fluid,  and  thus  come  to  lie  eventually  for  the  most  part  within  the 
peritoneal  cavity.  In  either  case,  rupture  of  the  sac  takes  place 
usually  within  three  to  four  months,  though,  when  the  sac-walls  are 
reenforced  by  adhesions  to  the  peritoneal  coverings  of  adjacent  viscera, 
the  full  term  of  gestation  may  be  reached. 

Abdominal  Pregnancy. — The  origin  of  abdominal  pregnancies  is 
unsettled.  As  no  instances  have  been  observed  at  an  early  period 
of  development,  it  is  not  possible  to  say  whether  the  fertilized  ovum 
drops  into  the  peritoneal  cavity  on  escaping  from  the  ovary  or  during 
its  migration  through  the  groove  of  the  long  ovarian  fibria,  or  whether 
nearly  all  cases  of  abdominal  pregnancy  are  not  really  secondary  out- 
growths from  the  tubal  and  ovarian  forms. 

Wherever  the  ovum  comes  in  contact  with  the  peritonaeum,  a  con- 
nective-tissue proliferation  is  set  up,  which  surrounds  it  with  a  vas- 
cular sac.  The  latter  often  attains  a  degree  of  thickness  which  renders 
it  comparable  to  the  gravid  uterus  (Klob).  The  walls  keep  pace,  as 
a  rule,  with  the  growth  of  the  ovum,  and,  as  they  extend  into  the 
abdominal  cavity,  form  adhesions  to  the  intestines,  the  mesentery,  and 
omentum.    It  is  claimed  that  organic  muscular  fibers  have  been  found 

*  Vide  Bandl,  Billroth's  "  Ilandbuch  der  Fraucnkrankheiten,"  5te  Abschn.,  p.  47. 

f  Vide  Spiegelbeug,  "  Zur  Casuistik  der  Ovarialschwangerschaft,"  "  Arch,  f .  Gynaek.," 
Bd.  xiii,  p.  73;  Landau,  "Zur  Lehre  von  der  Eierstocksschwangerschaft,"  ibid.^  Bd. 
xvii,  p.  436 ;  Schuoeder,  "  Lchrbuch,"  4te  Aufl.,  p.  385. 


316 


THE  PATHOLOGY  OF  PREGNANCY. 


in  the  sac,  especially  near  the  uterine  attachment.  In  this  form  the 
foetus  most  frequently  reaches  maturity. 

In  rare  cases  the  ovum  develops  free  in  the  abdominal  cavity,  with- 
out the  formation  of  pseudo-membranes,  the  foetus  being  surrounded 
solely  by  the  amnion  and  chorion. 

Still  more  remarkable  are  the  so-called  secondary  abdominal  preg- 
nancies, where  rupture  of  the  sac  and  the  fetal  membranes,  whether 
primarily  situated  in  the  tubes,  the  ovary,  or  the  abdominal  cavity, 
takes  place,  and  the  foetus  passes  into  the  abdominal  cavity.  Usually 
the  child  dies  at  or  soon  after  the  time  of  rupture,  but  cases  are  re- 
ported by  Walter,  Patuna,  and  Bandl,*  where  it  continued  to  develop 
within  the  abdomen.  The  presence  of  the  child  excites  an  active  pro- 
liferation of  connective  tissue,  by  means  of  which  a  secondary  sac  is 
formed.  If  the  child  dies,  it  may  either  become  converted  into  a 
lithopsedion,  or,  through  the  vascular  connective  tissue  by  which  it  is 
surrounded,  the  soft  structures  of  the  body  may  preserve  their  integ- 
rity for  years  succeeding  the  fatal  ending. 

There  are,  in  addition  to  the  varieties  already  mentioned,  histories 
on  record  of  the  coexistence  of  extra-uterine  and  intra-uterine  preg- 
nancies, the  latter  occurring  at  the  same  menstrual  period  as  the  for- 
mer, or  subsequent  to  the  death  of  the  extra-uterine  foetus,  f 

The  Symptoms  of  Extea-utekin^e  Pregn"akcy. 

The  earlier  symptoms  of  extra- uterine  pregnancy  do  not  materially 
differ  from  those  of  the  intra-uterine  form.  Menstruation  usually 
ceases,  though  not  with  the  same  regularity  as  in  normal  pregnancy. 
The  recurrence  of  the  monthly  flow  for  one  or  two  periods  is  not  an 
uncommon  incident.  In  some  cases,  too,  a  nearly  continuous  sero- 
sanguinolent  discharge  of  moderate  extent  has  been  observed.  Up  to 
a  certain  point  the  hypertrophic  changes  of  the  uterus  take  place  in 
the  usual  manner.  The  mucous  membrane  is  converted  into  a  de- 
cidua,  and  a  mucous  plug  fills  the  cervix.  In  general  terms,  the  length 
of  the  uterus  is  greater,  the  closer  the  contiguity  of  the  ovum  to  the 
uterus.  Thus,  in  interstitial  pregnancies  the  length  has  been  found 
to  vary  between  four  and  seven  inches,  in  tubal  pregnancies  the  aver- 
age enlargement  is  less  than  in  the  interstitial,  and  in  the  abdominal 
less  than  in  the  tubal  form.  In  a  few  cases  of  tubal  pregnancy  there 
has  been  no  increase  in  the  size  of  the  uterus.  The  extra-uterine 
ovum  may,  in  the  course  of  its  growth,  drag  the  uterus  upward,  or 
push  it  downward,  forward,  or  sideways,  according  to  the  site  of  its 
development. 

Characteristic  symptoms  of  extra-uterine  pregnancy  do  not  occur 
until  the  ovum  has  reached  a  certain  degree  of  growth,  and  in  some 
cases  not  until  rupture  has  taken  place.    Often  preceding  rupture,  or, 

*  Bandl,  loc.  cit.,  p.  G3.  f  Ibid.,  p.  66. 


EXTRA-UTERINE  PREGNANCY. 


317 


in  abdominal  pregnancies,  the  death  of  the  foetus,  the  patient  suffers 
from  paroxysmal  pains  in  the  sac,  and  uterine  pains  of  a  labor-like 
character.  The  latter  are  associated  with  a  sero-sanguinolent  dis- 
charge, and  are  followed  by  the  expulsion  of  portions  of  the  decidua. 

The  symptoms  of  rupture  are  the  usual  ones  of  internal  haemor- 
rhage, viz.,  yawning,  languor,  fainting,  clammy  perspiration,  rapid 
pulse,  intermittent  vomiting,  collapse,  and  acute  anaemia.  After  the 
death  of  the  ovum  these  symptoms  may  cease  and  not  return  again  ; 
whereas,  if  the  ovum  continues  to  grow,  there  may  be  repeated  attacks 
of  haemorrhage  and  local  peritonitis,  terminating  finally  in  death  or 
recovery. 

When  the  death  of  the  ovum  does  not  occur  within  the  first  three 
to  four  months,  the  pressure  of  the  tumor  usually  gives  rise  to  dysuria 
and  constipation. 

Terminations, — In  tubal  and  interstitial  pregnancies  the  usual 
terminations  are,  as  we  have  seen,  rupture  of  the  sac,  haemorrhage, 
l)eritonitis,  and  death.  It  is  well  to  bear  in  mind,  however,  that  this 
is  not  the  history  of  all,  a  pretty  large  percentage  ending  in  recovery. 
Thus,  a  dead  foetus  may  be  retained  for  years  without  furnishing  the 
impulse  to  a  fatal  issue.  When  the  foetus  dies  previous  to  rupture, 
the  ovum  may  degenerate  into  a  mole,  or  the  foetus  may  either  undergo 
mummification,  or  be  converted  into  a  lithopaedion. 

In  abdominal  pregnancies,  whether  primary  or  secondary,  the  ovum 
or  foetus  usually  excites  a  local  peritonitis,  attended  with  pain  and 
fever,  and  followed  by  the  production  of  pseudo-membranes,  which 
exercise  a  conservative  influence  by  shutting  off  the  ovum  from  the 
peritoneal  cavity.  Indeed,  in  the  exceptional  instances  where  these 
inflammatory  conditions  do  not  develop,  the  movements  of  the  foetus 
within  its  own  membranes  may  give  rise  to  such  intense  suffering  as 
to  cause  the  woman  to  die  from  exhaustion  (Schroeder). 

In  ovarian  and  abdominal  pregnancies  the  child  may  die  prema- 
turely, or  gestation  may  advance  to  full  term.  In  the  latter  instances 
labor-pains  set  in,  the  decidua  is  expelled,  and  the  child  dies  during 
the  expulsive  efforts.  In  the  majority  of  cases  the  dead  foetus  excites 
a  suppurative  inflammation  in  the  sac  by  which  it  is  inclosed,  and  the 
patient  dies  either  from  general  peritonitis  or  from  profuse  suppura- 
tion. In  favorable  cases,  where  the  peritonitis  remains  local  and  the 
suppuration  is  tolerated,  fistulous  communications  may  form  with  one 
of  the  hollow  viscera  of  the  abdominal  walls,  through  which  the  con- 
tents of  the  sac  may  be  eliminated.  Most  frequently  the  opening 
takes  place  into  the  large  intestine  ;  quite  often  through  the  abdom- 
inal walls  ;  more  rarely  into  the  vagina  and  bladder.  In  any  case, 
the  process  of  elimination  is  slow,  often  lasting  months  and  even  years. 
W^hen  the  bones  and  soft  tissues  have  all  been  discharged,  complete 
recovery  may  take  place.    In  the  larger  proportion  of  cases,  however. 


318 


THE  PATHOLOGY  OF  PREGNANCY. 


if  Nature  is  not  assisted,  the  patient  perishes  from  exhaustion  and 
blood-poisoning  before  the  elimination  is  ended  (Schroeder). 

Sometimes  the  foregoing  inflammatory  changes  do  not  occur  as  the 
result  of  the  death  of  the  foetus,  in  which  case  the  fluid  contents  of  the 
sac  are  reabsorbed,  and  the  walls  collapse  and  come  in  contact  with  the 
fetal  cadaver.  The  skin  of  the  latter,  and  at  a  later  period  the  deep- 
seated  soft  tissues,  undergo  fatty  degeneration,  and  form  a  greasy  sub- 
stance, consisting  of  fat,  lime-salts,  cholesterin-crystals,  and  blood-pig- 
ment. Afterward  the  fluid  portions  are  absorbed,  so  that  nothing 
remains  but  the  bones,  lime  lamellae,  and  incrustations  upon  the  walls 
of  the  sac,  or  the  foetus  may  shrink  up  like  a  mummy,  preserving  its 
shape  and  organs  to  the  minutest  detail  (Spiegelberg).  A  foetus  thus 
altered  is  termed  a  lithopsedion.  It  may  remain  imbedded  in  connec- 
tive tissue  for  years  without  injury  to  the  mother.  The  lithopaedion  of 
Leinzell  was  removed  in  1720  from  a  woman  ninety-four  years  of  age, 
who  had  carried  it  for  forty-six  years.  The  presence  of  the  lithopae- 
dion  does  not  prevent  pregnancy  from  taking  place.*  In  some  cases  it 
may  after  years  excite  suppuration,  a  result  which  is  fostered,  according 
to  Spiegelberg,  by  pregnancy  and  labor.  Eecovery  may  follow  the 
artificial  extraction  of  the  foreign  body,  or  death  may  result  from 
inflammation  and  the  discharge  of  pus. 

Diagnosis. — The  diagnosis  of  extra-uterine  fetation  is  based  upon 
the  existence  of  the  signs  of  pregnancy,  the  exclusion  of  an  ovum 
within  the  uterine  cavity,  and  the  presence  of  a  tumor  external  to  the 
uterus. 

In  tubal  pregnancy,  the  symptoms  up  to  the  time  of  rupture  are 
often  those  of  ordinary  pregnancy.  The  existence  of  paroxysmal 
pains,  radiating  from  one  iliac  fossa,  should  excite  the  suspicions  of 
the  physician  and  lead  to  a  careful  investigation.  As  these  pains  are 
ordinarily  associated  with  flatulent  distention  of  the  colon,  they  are  apt 
to  be  regarded  as  due  to  intestinal  colic.  Sero-sanguinolent  discharges 
from  the  uterus,  and  afterward  the  expulsion  of  portions  of  the  de- 
cidua,  would,  however,  limit  the  diagnosis  to  a  choice  between  mem- 
branous dysmenorrhoea  and  the  condition  in  question,  the  decision 
depending  upon  the  presence  or  absence  of  the  menstrual,  mammary, 
and  uterine  signs  of  pregnancy.  An  examination  per  vaginam,  after 
the  first  five  or  six  weeks,  reveals  the  presence  of  a  tumor  to  the  side 
of  the  uterus.  When  situated  low  down,  whether  in  the  cul-de-sac  of 
Douglas,  or  to  the  sides  of  the  vagina,  by  conjoined  palpation  its 
ovoid  shape,  fluctuation  in  the  sac,  and,  in  the  absence  of  peritoneal 
adhesions,  a  ballottement  of  the  entire  tumor,  can  be  made  out.  Bal- 
lottement  of  the  foetus  may  be  detected  by  the  end  of  the  fourth 
month.  Arterial  pulsations  in  the  vaginal  walls  beneath  the  tumor  are 
of  suspicious  import. 

*  SciiuoEDKR,  op.  cit.^  6tc  Aufl.,  p.  421. 


EXTRA-UTERINE  PREGNANCY. 


319 


Owing  to  the  desirability  of  early  recognizing  an  extra-uterine 
pregnancy,  when  the  evidence  in  favor  of  its  existence  is  very  strong 
it  is  allowable  to  demonstrate  the  empty  state  of  the  uterus  by  a  care- 
ful introduction  of  the  sound,  or,  still  more  clearly,  by  introducing 
the  finger  after  preliminary  dilatation  of  the  cervix. 

When  the  sac  ruptures  in  the  early  weeks  of  pregnancy,  the  escape 
of  blood  into  the  peritoneal  cavity  may  be  moderate  and  run  the 
course  of  ordinary  haematocele.  From  the  third  to  the  fourth  month, 
rupture  gives  rise  to  symptoms  of  extensive  internal  haemorrhage,  and 
usually  proves  speedily  fatal. 

With  rare  exceptions,  when  extra-uterine  pregnancy  exceeds  the 
fourth  month  without  the  occurrence  of  rupture,  either  an  ovarian  or 
abdominal  pregnancy  may  be  predicated.  After  the  fourth  month  the 
ovum  becomes  of  the  size  of  the  two  fists,  and  it  is  sometimes  possible 
to  make  out  the  presence  of  fetal  parts  through  the  abdominal  walls, 
provided  the  latter  are  not  too  thick.  Of  course,  as  pregnancy  ad- 
vances, the  heart-sounds  and  the  contour  of  the  foetus  become  more 
distinct.  The  difference  between  intra-  and  extra-uterine  pregnancy 
may  sometimes  be  established  by  frictions  of  the  abdomen  over  the 
tumor  with  the  hand,  as  the  uterus  alone  contracts  in  response  to  the 
stimulus. 

If  by  the  foregoing  means  the  requisite  certainty  is  not  reached, 
bimanual  examination  should  be  made  under  anaesthesia.  Sometimes 
the  diagnosis  can  only  be  decided  by  the  introduction  of  the  sound  or 
a  finger  into  the  uterus,  the  physician  assuming  the  risk  of  premature 
labor,  should  he  find  his  supposition  of  extra-uterine  pregnancy  an 
error. 

Treatment. — The  treatment  of  extra-uterine  fetation  varies  in  ac- 
cordance with  the  stage  of  pregnancy  and  the  condition  of  the  foetus. 
For  the  sake  of  convenience,  we  distinguish — 1.  Cases  of  early  gesta- 
tion ;  2.  Cases  of  advanced  gestation  (foetus  living)  ;  3.  Cases  of 
gestation  prolonged  after  the  death  of  the  foetus. 

1.  Cases  of  Early  Gestation. — The  indication  for  treatment  in 
the  early  months  is  plainly  the  adoption  of  measures  to  destroy  the  life 
of  the  foetus,  and  thus,  by  arresting  the  growth  of  the  ovum,  avert  the 
danger  of  rupture  and  haemorrhage.  Indeed,  in  this  way  we  simply 
follow  the  plan  marked  out  for  us  by  Nature,  spontaneous  recovery 
commonly  following  the  accidental  death  of  the  embryo. 

The  methods  which  have  heretofore  been  employed  to  destroy  the 
ovum  are  puncture  of  the  sac,  injections  of  morphia  solutions,  elytrot- 
omy,  and  the  faradaic  current. 

Puncture  of  the  Sac. — Puncture  of  the  sac  is  usually  easily  effected 
by  the  introduction  of  an  exploring  trocar,  through  either  the  vagi- 
nal or  rectal  wall.  The  operation  is  to  be  recommended  on  the  score 
of  simplicity,  but  has  not  been  attended  with  very  brilliant  results. 


320 


THE  PATHOLOGY  OF  PREGNANCY. 


Recoveries  after  puncture  have  been  recorded  by  Greenhalgh,  Tanner, 
Stoltz,  Jacobi,  Koeberle,  and  E.  Martin  (two  cases).  Fatal  issues 
from  septicaemia  and  peritonitis  followed  puncture  in  the  hands  of 
Routh,  J.  Y.  Simpson,  A.  Simpson,  Martin,  Braxton  Hicks,  Thomas 
(two  cases),  Conrad,  Netzel,  Hutchinson,  John  Scott,  Gallard,  and 
Depaul.  Frankel  *  withdrew  nearly  three  fifths  of  an  ounce  of  amni- 
otic fluid  from  the  sac  without  interrupting  the  course  of  pregnancy. 

Injectiojis  of  Solutions  into  the  Sac,  designed  to  destroy  the  Fcetus. 
— This  method  was  first  suggested  by  Joulin.f  He  proposed  injec- 
tions of  sulphate  of  atropia  (one  fifth  of  a  grain,  dissolved  in  a  few 
drops  of  water)  into  the  sac  by  means  of  a  long  hypodermic  syringe. 
His  suggestion  subsequently  was  successfully  carried  into  effect  in  two 
cases  by  Friedreich,  J;  of  Heidelberg.  The  needle  of  the  syringe  should 
be  introduced  into  the  sac  through  the  abdominal  or  vaginal  walls,  a 
few  drops  of  fluid  should  then  be  withdrawn,  and  its  place  supplied  by 
the  solution  containing  the  poison  selected.  Friedreich  employed  by 
preference  a  fifth  of  a  grain  of  morphia.  The  operation  should 
be  repeated  every  second  day,  until  the  diminished  size  of  the  ovum 
affords  evidence  that  the  result  sought  for  has  been  accomplished. 
The  operation  seems  to  produce  but  slight  inflammatory  disturbance, 
and  the  maternal  system  has  been  found  not  to  feel  the  influence  of  the 
narcotic. 

Elytrotomy. — Professor  Gaillard  Thomas  reports  a  case  where  he 
cut  into  the  sac  through  the  vagina  by  means  of  the  incandescent 
knife  attached  to  the  electric-cautery  apparatus.  The  patient  nar- 
rowly escaped  with  her  life,  but  finally  recovered.  In  the  latest  edi- 
tion of  his  work  on  diseases  of  women,  Dr.  Thomas  recommends 
Paquelin's  cautery  brought  to  a  red  heat.  After  cutting  slowly 
through  the  sac,  he  advises  removing  the  foetus,  but  not  the  placenta, 
and  then  filling  the  sac  with  antiseptic  cotton,  which  should  be  re- 
moved once  in  thirty-six  hours.  He  offers  the  operation  only,  how- 
ever, in  cases  where  the  severity  of  the  symptoms  demands  immediate 
action. 

The  Faradaic  and  Galvanic  Currents. — The  transmission  of  the 
faradaic  current  through  the  ovum  has  proved  a  safe  and  efficient 
method  for  destroying  the  life  of  the  foetus  during  the  first  three 
months  of  its  existence.  The  application  consists  in  passing  one  pole 
into  the  rectum  to  the  site  of  the  ovum,  and  pressing  the  other  upon 
a  point  in  the  abdominal  wall  situated  two  to  three  inches  above  Pou- 

*  Frankel,  "  Zur  Diagnostik  und  operative  Bchandlung  der  Tubcnschwangerschaft, 
"Arch,  f.  Gynack.,"  Bd.  xiv,  p.  197. 

f  JouLiN,  "  Traite  eomplet  des  accoucliements,"  p.  968. 

:}:  CoHNSTEiN,  Bcitrag  zur  Schwangerschaft  ausserhalb  der  Gcbarmutter,"  "Arch, 
f.  Gynack.,"  Bd.  xiv,  p.  355.  Hcnnig  reports  likewise  a  case  operated  on  by  Koeberle, 
where  profuse  haemorrhage  occurred.  It  is  not  stated  whether  the  patient  recovered. 
("  Die  Krankheitcn  der  Eilciter  und  die  Tubcnschwangerschaft,"  p.  138.) 


EXTRA-UTERINE  PREGNANCY. 


321 


part's  ligament.  The  full  force  of  the  current  of  an  ordinary  one-cell 
battery  should  be  employed  for  a  period  varying  from  five  to  ten  min- 
utes. The  treatment  should  be  continued  daily  for  one  or  two  weeks, 
until  the  shrinkage  of  the  tumor  leaves  no  doubt  as  to  the  death  of 
the  foetus. 

The  successful  employment  of  the  faradaic  current  in  extra-uterine 
pregnancy  we  owe  to  Dr.  J.  G.  Allen,  who  reported  two  cases  of 
recovery  through  its  instrumentality  in  1872.  His  first  case  occurred 
in  1869,  the  second  in  1871.  Previously,  in  1859,  Burci  had  succeeded 
in  shriveling  up  the  ovum,  in  a  case  of  tubal  pregnancy,  with  the 
galvanic  current  transmitted  through  the  tumor  by  means  of  two 
acupuncture-needles.  In  1866  Dr.  Braxton  Hicks  tried  the  faradaic 
current,  but  abandoned  it  after  the  second  application.  Dr.  Allen  was 
apparently  in  no  haste  to  report  his  triumphs,  but  appears  to  have 
mentioned  them  incidentally  in  the  course  of  a  discussion  before  the 
Obstetrical  Society  of  Philadelphia.  So  little  pains  did  he  take  re- 
garding his  discovery,  that  the  subject  was  nearly  forgotten,  until  a 
new  success  was  reported  by  Drs.  Lovering  and  Land  is,  of  the  Starling 
Medical  College,  in  1877.  Since  then,  Landis  has  reported  a  second 
case  of  recovery,  and  one  each  has  occurred  in  the  practice  of  J.  C. 
Reeve,*  H.  P.  C.  Wilson,!  Harrison,  and  the  writer.  In  three  cases, 
treated,  one  by  Dr.  McBurney,J;  one  by  Dr.  C.  E.  Billington,  and  one 
by  Dr.  Rockwell,  the  galvanic  current,  with  one  hundred  and  twenty 
interruptions  to  the  minute,  was  employed  with  equally  favorable 
results.* 

The  treatment  in  my  own  case  was  begun  at  the  end  of  the  tenth 
week,  dating  from  the  last  menstruation.  The  tumor  was  at  that 
time  felt  quite  low  down  upon  the  right  side  of  the  vagina,  fluctuation 
was  distinct,  and  by  conjoined  palpation  ballottement  of  the  entire 
ovum  could  be  produced.  The  diagnosis  was  confirmed  by  Dr.  Gail- 
lard  Thomas,  who  saw  the  case  with  me  in  consultation.  At  his  sug- 
gestion, I  tried  Allen's  method,  though  skeptical  as  to  any  benefit  to 
be  derived  from  it.  As  no  perceptible  effect  was  produced  by  the  first 
three  seances,  and  as  I  believed  rupture  was  imminent,  I'  became  ex- 
tremely anxious  to  make  the  vaginal  incision  at  once.  In  a  second 
consultation  with  Dr.  Thomas,  I  was,  however,  persuaded  to  persevere, 
and  was  rewarded  by  finding,  upon  the  tenth  application,  such  dis- 

*  Reeve,  "Trans,  of  the  Amer.  Gyngec.  Soc,"  vol.  iv,  p.  313.  Allen's  case  is  referred 
to  by  Reeve. 

f  Wilson,  "  Amcr.  Jour,  of  Obstet.,"  vol.  xiii,  p.  836. 

X  McBuRNEY,  "Case  of  Tubo-Interstitial  Pregnancy,"  "New  York  Med.  Jour.,"  vol. 
xxvii,  p.  273. 

*  Verbal  report  of  Dr.  Rockwell  at  the  County  Society,  in  the  discussion  following  the 
reading  of  a  paper  by  the  author  on  the  "Treatment  of  Extra-Uterine  Pregnancy."  In 
the  McBurney  case  two  applications,  in  Billlngton's  four,  and  in  Rockwell's  a  single 
application,  sufficed  to  destroy  the  embryo. 

21 


322 


THE  PATHOLOGY  OF  PREGNANCY. 


tinct  evidences  of  suspended  growth  that  I  felt  justified  in  leaving  the 
case  to  Nature.  The  swelling  has  since  nearly  disappeared,  and  con- 
valescence has  progressed  without  interruption. 

When  the  tube  ruptures  without  previous  warning,  treatment 
should  be  directed  to  the  arrest  of  internal  haemorrhage  and  the  re- 
moval of  shock.  An  ice-bag  applied  to  the  abdomen  meets  the  first 
indication,  but  it  is  to  be  employed  with  circumspection  where  great 
depression  already  exists.  Compression  of  the  aorta,  or  a  sand-bag 
laid  upon  the  abdomen  over  the  site  of  the  ovum,  may  prove  of  service. 
The  patient  should  be  cautioned  to  maintain  the  most  perfect  quiet ; 
opiates  should  be  administered,  and  stimulants  should  be  given  in 
small  quantities,  but  at  short  intervals.  The  subsequent  treatment 
should  be  that  for  peritonitis. 

Laparotomy. — As,  under  careful  management,  rupture  of  the  tube 
most  often  proves  fatal,  Kiwisch  recommended  in  such  cases  to  make 
an  incision  four  or  five  inches  in  length  through  the  abdominal  wall 
along  the  linea  alba.  In  order  to  be  sure  that  internal  haemorrhage 
had  really  taken  place,  he  advised,  when  the  peritonaeum  was  reached, 
to  first  make  a  small  puncture,  and  to  introduce  a  pipette  into  the 
abdominal  cavity.  If  the  presence  of  blood  was  detected,  the  perito- 
naeum should  then  be  laid  open  the  length  of  the  abdominal  wound, 
and,  after  first  tying  the  bleeding  vessels,  the  sac  should  be  removed, 
and  the  peritonaeum  carefully  cleansed.  Strange  to  say,  intelligent  as 
these  instructions  seem,  no  one,  in  these  days  of  abdominal  surgery, 
has  so  far  had  the  hardihood  to  carry  them  into  execution.  The  rea- 
sons for  this  backwardness  are  probably  to  be  found  in  the  uncertain- 
ties of  the  diagnosis,  the  risk  of  finding  the  sac  hopelessly  matted  to 
the  adjacent  viscera,  the  dislike  for  operating  upon  a  dying  woman, 
and  the  fact  that  a  considerable  number  of  spontaneous  recoveries 
occur,  either  from  the  mummification  of  the  foetus,  or  by  the  limita- 
tion of  the  sanguineous  effusion  and  the  production  of  a  circumscribed 
haematocele. 

2.  Cases  of  Advanced  Gestation  (Foetus  livmg).  —  During  the 
progress  of  gestation,  most  patients  suffer  from  transient  though  often 
severe  attacks  of  peritoneal  inflammation,  from  pains  caused  by  the 
fetal  movements,  from  irregular  uterine  haemorrhages,  from  inability 
to  take  food,  and  from  the  resulting  emaciation  and  depression  of  the 
vital  powers.  The  occurrence  of  labor  is  apt  to  excite  peritonitis,  and 
may  be  associated  with  separation  of  the  placenta,  haemorrhage  into 
the  sac,  and  disruption  of  the  sac-walls.  These  manifold  sources  of 
danger  have  been  advanced  as  grounds  for  early  operative  interference  ; 
and  assuredly  laparotomy,  furnishing,  as  it  does,  an  opportunity  to 
rescue  the  child  from  certain  death,  ought  to  enjoy  the  higliest 
degree  of  favor,  provided  its  performance  does  not  at  the  same  time 
increase  the  jeopardy  in  which  the  mother's  life  is  placed.    To  de- 


EXTRA-UTERINE  PREGNANCY. 


323 


cide  this  point,  it  is  necessary  to  inquire  as  to  the  results  thus  far 
obtained  from  its  employment.  Parry  reported  twenty  cases  of  so- 
called  primary  operations — i.  e.,  operations  performed  during  the  life 
of  the  child — by  means  of  which  eight  children  and  six  mothers  were 
saved.  This,  though  not  a  particularly  brilliant  showing,  was  thought 
to  furnish  encouragement  to  continued  trial,  with  the  belief  that  ex- 
perience would  so  far  lead  to  improvements  in  methods  of  operating 
and  in  the  care  of  patients,  as  eventually  to  raise  laparotomy  for  the 
removal  of  an  extra-uterine  foetus  to  the  level  of  other  forms  of  ab- 
dominal surgery.  An  examination  of  Parry's  table  does  not,  however, 
warrant  his  frequently  quoted  statement.  Five  of  the  reported  mater- 
nal recoveries  ought  to  be  stricken  out  altogether.*  For  the  sixth  case, 
that  of  Hooper  (Xo.  14),  it  is  simply  stated  that  the  cyst  had  burst 
into  the  bowel,"  and  that  the  child  was  dead.  Whether  the  death  of 
the  child  long  preceded  the  ojoeration,  it  is  impossible  to  determine. 
Litzmann  \  furnishes  the  results  of  nine  additional  operations,  with 
only  one  recovery,  viz.,  the  now  famous  case  of  Jessup.  Thus,  in 
twenty-four  cases  of  primary  operation,  only  one  mother  certainly  sur- 
vived. If  we  admit  Hooper's  case,  the  result  will  stand  twenty-two 
deaths  and  two  recoveries,  li  we  accept  Parry's  statement  as  approxi- 
mately correct — that  in  499  cases  of  extra-uterine  pregnancy,  includ- 
ing 174  cases  of  ruptured  cyst,  the  mortality  was  67*2  per  cent. — it  is 
evident  that  much  remains  to  be  done  in  the  way  of  perfecting  the 
primary  operation  before  its  admissibility,  except  under  desjDerate  con- 
ditions, can  be  recognized.  In  ten  cases  reported  by  Litzmann,  only 
four  children  survived  the  third  day. 

The  unavoidable  source  of  danger  in  the  primary  oj^eration  lies  in 
the  impossibility  of  removing  the  placenta,  owing  to  the  absence  of 
any  physiological  contrivance  to  check  haemorrhage  from  the  maternal 
vessels.  Even  when  the  placenta  is  left  in  situ,  fetal  haemorrhages 
may  occur  during  the  process  of  its  elimination.  Again,  in  the  pro- 
portion of  one  case  to  six,  the  placenta  has  been  found  in  the  line  of 
the  abdominal  incision. 

*  Vide  Parry,  "  On  Extra-Uterine  Pregnancy,"  p.  229.  Cases  5  and  6  are  the  same. 
They  were  found  by  Parry  in  different  journals,  in  one  case  ascribed  to  Schreyer,  who  was 
the  principal  in  the  operation,  and  in  another  to  Zwanck,  who  was  present  as  an  assistant. 
Litzmann,  on  seemingly  good  grounds,  maintains  that  Schreyer  simply  performed  Caesarean 
section  upon  a  one-horned  uterus. 

In  De  Coene's  case  (No.  9)  of  twin  pregnancy,  one  of  the  children  passed  into  the 
abdominal  cavity  through  an  opening  in  the  uterus  formed  by  the  gaping  of  the  line  of 
union  at  the  site  of  a  previous  Caesarean  section. 

In  Stiitter's  case  (No.  10),  the  operation  was  performed  in  the  forty-fifth  week,  six 
weeks  after  the  death  of  the  foetus. 

In  Ramsbotham  and  Adams's  case  (No.  11),  the  foetus  had  been  dead  six  months — 
operation  in  the  fifteenth  to  the  sixteenth  month  (Litzmann). 

f  Litzmann,  "  Zur  Feststellung  der  Indicationen  fiir  die  Gastrotomie  bei  Schwanger- 
schaft  ausserhalb  der  Gcbarmutter." 


324 


THE  PATHOLOGY  OF  PREGN^ANCr. 


The  extraction  of  a  living  child  through  an  incision  in  the  vaginal  wall  was 
reported  by  Dr.  John  King,  of  Georgia,  in  1817.  The  mother  made  an  easy  recov- 
ery. Campbell  reports  nine  cases,  with  the  saving  of  five  mothers  and  five  chil- 
dren. Parry  increased  the  number  to  fifteen,  with  six  recoveries.  No  recent 
successes  have  been  announced.  Bandl,*  in  1874,  operated  under  what  he  re- 
garded as  most  favorable  conditions,  but  the  patient  died  at  the  beginning  of  the 
third  day.  The  operation  is  only  applicable  to  cases  where  the  sac  is  low 
down  in  the  pelvis,  and  the  presenting  part  can  be  easily  reached  through  the 
cnl'de-sac  of  Douglas. 

3.  Cases  of  Gestation  prolonged  after  the  Death  of  the  Foetus. — 
It  is  an  accepted  rule  not  to  operate  in  advanced  extra-uterine  preg- 
nancy during  the  continuance  of  labor-pains,  as  the  expulsive  efforts 
at  the  same  time  diminish  the  chance  of  saving  the  life  of  the  child, 
and  increase  the  danger  of  the  mother.  Opiates  should  be  adminis- 
tered and  absolute  rest  enjoined,  with  the  view  of  hindering  the  separa- 
tion of  the  placenta,  an  accident  necessarily  followed  by  haemorrhage, 
and  possibly  by  rupture  of  the  sac. 

After  the  death  of  the  foetus,  the  most  favorable  result  consists  in 
absorption  of  the  amniotic  fluid,  continued  shrinkage  of  the  sac,  and 
the  conversion  of  the  foetus  into  a  lithopsedion.  More  commonly, 
however,  the  foetus  undergoes  maceration,  and  the  amniotic  fluid,  soiled 
with  meconium  and  serum,  stained  with  dissolved  coloring-matters 
of  the  blood,  becomes  turbid  and  of  a  dirty-red,  reddish-brown,  gray, 
or  greenish-yellow  color.  The  patient  suffers  from  attacks  of  pain, 
due  to  peritoneal  irritation,  from  loss  of  appetite,  vomiting,  and  diar- 
rhoea, from  fever  with  irregular  chills,  from  emaciation,  and  general 
prostration.  Owing  probably  to  the  contiguity  of  the  intestines 
(Litzmann),  septic  germs  are  liable  at  any  time  to  pass  into  the  sac, 
and  excite  decomposition.  When  an  incision  is  then  made  to  remove 
the  foetus,  the  latter  is  found  in  a  putrid  condition,  and  the  amniotic 
fluid  consists  of  a  chocolate-brown,  purulent  menstruum  of  greater  or 
less  consistence.  The  nature  of  the  changes  that  have  taken  place  is 
evidenced  by  foul  odors  and  the  escape  of  stinking  gases.  It  is  ob- 
vious, therefore,  that  the  presence  of  a  dead  foetus  seriously  compro- 
mises the  safety  of  its  possessor.  To  be  sure,  many  cases  have  been  re- 
corded where  eventually  suppurative  processes  have  led  to  the  forma- 
tion of  fistulous  openings  communicating  with  the  abdominal  walls, 
the  rectum,  the  vagina,  and  even  the  bladder,  through  which  the  fluid 
contents  first  escape  from  the  sac,  and  afterward  the  piecemeal  elimi- 
nation of  the  foetus  spontaneously  takes  place.  As,  under  the  circum- 
stances, the  enlargement  of  the  openings  into  the  cyst,  the  removal  of 
the  contents,  and  the  treatment  of  the  cavity  like  an  ordinary  abscess, 
are  attended  with  but  moderate  risk  (three  deaths  in  twenty-nine  cases 
of  abdominal  fistula,  according  to  Parry),  it  has  been  proposed  to  post- 

*  Billroth,  "  Handbuch  der  FrauenkranUhciten,"  5te  Abschn.,  p.  87. 


EXTRA-UTERINE  PREGNANCY. 


325 


pone  surgical  aid  until  Nature  indicates  the  channel  by  which  elimi- 
nation is  to  be  effected.  This  proposition,  however,  ignores  the  de- 
plorable condition  to  which  the  suppurative  process  inevitably  reduces 
the  patient,  and  the  incidental  dangers  to  life. 

During  the  last  decade,  the  success  of  secondary  laparotomy,  as 
distinguished  from  that  performed  during  the  life  of  the  foetus  on  the 
one  hand,  and  simple  incisions  designed  to  enlarge  fistulous  openings 
on  the  other,  has  been  such  as  to  warrant  its  being  placed  in  the  cate- 
gory of  justifiable  operative  procedures.  In  thirty-three  cases  collected 
by  Litzmann  (twenty-four  between  1870  and  1880),  there  were  nine- 
teen recoveries.  Of  the  two  dangers  inherent  to  the  primary  operation, 
viz.,  haemorrhage  and  septicaemia,  the  former  is  greatly  lessened  by 
the  cessation  of  the  fetal  circulation  and  by  the  gradual  thrombosis 
and  obliteration  of  the  maternal  vessels,  and  the  cutting  off  of  the 
blood-supplies  to  the  placenta.  With  the  present  perfection  to  which 
antiseptic  measures  have  been  carried,  the  risks  from  septicaemia  are 
diminished  though  not  entirely  done  away  with. 

The  time  for  the  performance  of  laparotomy  is  of  some  impor- 
tance. All  of  Litzmann's  patients  which  were  operated  upon  during  the 
first  month  subsequent  to  the  decease  of  the  foetus  (seven  in  number) 
died,  while,  in  twenty-six  cases  operated  upon  at  periods  varying 
from  five  weeks  to  a  year  after  the  decease  of  the  foetus,  there  were 
but  seven  deaths.  The  former  mortality  was  partially  due  to  the  des- 
perate condition  of  the  patients,  wliich  determined  the  early  date  of 
the  operations,  and  in  part  to  the  occurrence  of  profuse  haemorrhages 
from  the  patent  mouths  of  the  placental  vessels.  There  are  as  yet 
no  signs  known  by  which  the  time  at  which  the  obliteration  of  the 
placental  vessels  becomes  complete  can  be  ascertained.  Schroeder  re- 
moved the  placenta  three  weeks  after  the  cessation  of  fetal  move- 
ments without  loss  of  blood,  while  a  patient  of  Depaul  expired  from 
placental  haemorrhage  from  an  operation  performed  four  months  after 
the  foetus  had  perished.  It  is  certainly  evident  that  when  the  circum- 
stances admit  of  delay  it  is  best  to  defer  operative  measures,  and  treat 
the  patient  symptomatically,  as  Litzmann  suggests,  with  pure  air, 
nourishing  food,  quinine,  and  gentle  laxatives,  until  the  obliteration 
of  the  maternal  vessels  has  probably  taken  place.  In  case,  however, 
of  marked  septic  symptoms,  the  opening  of  the  sac  should  not  be 
delayed,  as  the  subsequent  use  of  antiseptics  at  least  is  calculated  to 
restrain  the  pernicious  influence  of  the  decomposing  contents  upon 
the  entire  organism. 

The  operation  for  laparotomy  should  be  performed  with  antiseptic 
precautions.  The  incision  should  be  made  along  the  linea  alba.  In 
case  the  sac  is  not  found  adherent  to  the  abdominal  walls,  it  should  be 
stitched  to  the  cut  borders  of  the  abdominal  wound  previous  to  open- 
ing.   The  placenta  should  be  left  to  come  away  spontaneously,  un- 


326 


OBSTETRIC  SURGERY. 


less  it  occupies  the  site  of  the  incision.  The  wound  should  be  closed 
above  and  left  open  below  for  the  passage  of  the  cord,  and  the  intro- 
duction of  antiseptic  injections. 

No  rules  can  profitably  be  laid  down  as  to  the  plans  to  be  pursued 
in  the  enlargement  of  fistulous  openings.  Each  case  must  be  treated 
upon  its  own  merits,  and  the  surgical  aid  rendered  must  be  adapted 
to  the  individual  peculiarities  which  characterize  it. 


OBSTETEIO  SUEGEEY. 


CHAPTER  XVIIL 

THE  INDUCTION  OF  PREMATURE  LABOR. 

Induction  of  premature  labor. — Indications. — Contracted  pelvis. — Habitual  death  of  foetus- 
— Diseases  which  imperil  the  life  of  the  mother. — Operation. — Catheterisatio  uteri. 
— Intra-uterine  injections. — Rupture  of  membranes. — Mechanical  dilatation  of  cer- 
vix.— Vaginal  douches. — Tampon.— Choice  of  methods. — Care  of  the  child. — Artifi- 
cial abortion. 

The  induction  of  premature  labor  is  indicated  in  cases  in  which 
the  continuance  of  pregnancy,  or  delivery  at  full  term,  is  associated 
with  risks  to  mother  or  child,  or  to  both,  which  may  be  diminished 
by  bringing  pregnancy  to  a  close  at  an  early  period  after  the  foetus  is 
prepared  for  extra-uterine  existence.  The  time  at  which  the  latter 
begins  is  usually  placed  at  the  twenty-ninth  week.  As,  however,  the 
preservation  of  the  child  at  so  early  a  date  is  an  exceptional  occurrence, 
and  as  a  large  proportion  of  those  which  by  tender  care  are  made  to 
survive  the  first  dangers  of  immaturity  perish  in  infancy,  commonly 
falling  a  prey  to  hydrocephalus  or  to  intestinal  derangements,  the  in- 
terests of  the  child  call  for  the  postponement  of  the  operation  as  long 
as  practicable.  Where  the  choice  lies  with  the  physician,  the  provo- 
cation of  labor  is  usually  deferred  until  the  thirty-third  or  thirty- 
fourth  week.    The  principal  indications  are  : 

1.  Moderate  Degrees  of  Pelvic  Contraction. — In  flattened  pelves 
measuring  from  two  and  three  fourths  to  three  and  one  fourth  inches, 
and  in  equally  contracted  pelves  under  three  and  one  half  inches,  the 
passage  of  a  full-term  child  is  not  impossible,  though  usually  difficult 
and  dangerous.  By  inducing  premature  labor,  however,  owing  to  the 
smaller  size  of  the  foitus,  and  especially  to  the  increased  compressibility 
of  the  fetal  head,  we  are  enabled  to  diminish  the  mechanical  obstacles 


THE  INDUCTION  OF  PREMATURE  LABOR. 


327 


to  delivery,  and  thus  to  improve  the  prognosis  for  both  mother  and 
child.  To  the  mother  the  advantage  from  the  operation  is  in  all  cases 
decided,  while  to  the  child  not  much  is  gained  in  the  extreme  degrees 
of  contraction. 

The  time  at  which  gestation  should  be  interrupted  depends  upon 
the  size  of  the  pelvis  and  our  estimate  of  the  size  of  the  fetal  head. 
The  distance  from  the  lower  border  of  the  symphysis  to  the  promon- 
tory should  be  accurately  measured,  and  the  side-walls  of  the  pelvis 
carefully  explored.  Schroeder's  measurements  show  that  the  bipari- 
etal  diameter  of  the  head  is,  between  the  twenty-eighth  and  thirty-sec- 
ond week,  about  three  and  one  fourth  inches  ;  between  the  thirty-second 
and  thirty-sixth  week,  nearly  three  and  a  half  inches  ;  and  that  after 
the  thirty-sixth  week  the  increase  is  insignificant.* 

One  of  the  most  important  questions  to  be  decided  in  reference  to 
the  induction  of  labor  is  the  period  to  which  gestation  has  advanced. 
But  this,  in  the  absence  of  well-defined  signs,  it  is  easy  to  miscalculate.. 
Physicians  have  been  misled  by  the  large  size  of  the  uterus  in  twin 
pregnancies  and  hydramnion  into  provoking  labor  before  extra-uter- 
ine existence  was  possible. 

Ahlfeld  has  shown  that  the  long  axis  of  the  foetus,  when  flexed  in 
utero,  is  almost  exactly  one  half  its  entire  length  in  an  extended  position. 
He  proposes  measuring  the  former  with  a  Baudelocque  pelvimeter,  by 
placing  one  extremity  per  vaginam  upon  the  child's  head,  and  the 
other  upon  a  point  in  the  abdominal  walls  over  the  fundus  of  the 
uterus  at  which  the  breech  of  the  child  is  felt.  Very  nearly  the  same 
results  were  obtained  by  measuring  from  the  upper  border  of  the 
symphysis  in  place  of  passing  the  lower  branch  through  the  genital 
canal.  The  following  arrangement,  based  upon  his  tables,  places 
before  us  in  a  practical  way  the  result  of  his  investigations,  so  far  as 
they  apply  to  the  questions  involved  in  the  induction  of  premature 
labor  :  \ 


Axis  of  foetus. 

Length  of  foetus. 

Bi-parietal  diameter. 

Duration  of  pregnancy. 

10  inches. 

20  inches. 

'd^  inches. 

38-40  weeks. 

n 

19 

3i 

35-37 

9 

18 

3i 

31-34 

8 

16 

3 

29-30 

*  ScHROEDER,  "  Lchrbuch  der  Geburtshiilfe,"  4te  Aufl.,  p.  235.  It  is  to  be  remem- 
bered that  the  biparietal  diameter  is  capable  of  a  considerable  degree  of  compression, 
and  that  it  is  usually  the  bitemporal  rather  than  the  biparietal  diameter  which  has  to 
pass  the  narrowest  diameter  of  the  pelvis. 

\  The  arrangement  is  modified  from  one  furnished  by  Stahl  ("  Geburtshiilfliche  Ope- 
rationslehre,"  p.  47).  Owing  to  individual  differences  in  the  length  of  the  foBtus  at  the 
same  period  of  gestation,  a  considerable  source  of  error  inheres  to  the  Ahlfeld  method  of 
computation.  It  is,  however,  much  less  than  those  to  which  estimates  based  upon  the 
size  of  the  uterus  are  subject. 


828 


OBSTETRIC  SURGERY. 


2.  Habitual  Death  of  the  Foetus. — It  has  been  proposed  that,  when 
in  successive  pregnancies  the  foetus  perishes  in  utero  during  the  latter 
weeks  of  gestation,  labor  should  be  induced  after  the  period  of  viability 
has  been  reached,  but  before  the  time  at  which,  according  to  previous 
experience,  the  fatal  ending  was  to  be  expected.  This  plan  of  treat- 
ment does  not  apply  to  cases  where  death  is  due  to  syphilis,  as  a  better 
result  is  to  be  expected  by  subjecting  both  parents  in  advance  to  anti- 
syphilitic  treatment.  Little  benefit,  too,  would  be  derived  from  pre- 
mature labor  where  the  death  is  due  to  organic  diseases  of  the  foetus. 
But  where  death  is  the  result  of  inanition,  dependent  upon  maternal 
anaemia,  fatty  degeneration,  faulty  development  of  the  placenta,  or 
alterations  of  the  umbilical  cord,  the  operation  is  fully  justifiable. 
With  the  difficulty,  however,  of  making  the  diagnosis  and  fixing 
the  time  when  labor  should  be  induced,  there  have  been  but  few  cases 
in  which  the  procedure  has  furnished  favorable  results. 

3.  Diseases  which  imperil  the  Life  of  the  Mother. — In  these  cases 
the  operation  is  primarily  performed  in  the  interests  of  the  mother, 
and  is  indicated,  therefore,  even  when  the  child  is  known  to  have  per- 
ished. Sometimes,  however,  premature  labor  becomes  a  means  of 
saving  the  life  of  the  child,  which  shares  the  dangers  that  threaten 
the  maternal  existence.  In  this  category  belong  especially  chronic 
affections  of  the  heart  and  of  the  respiratory  organs  ;  enormous  disten- 
tion of  the  abdomen  from  multiple  pregnancy,  hydramnion,  tumors, 
and  ascites,  which  occasion  extreme  dyspnoea  ;  pernicious  anaemia  ;  un- 
controllable vomiting  ;  hagmorrhages  from  placenta  praevia ;  chorea ; 
convulsions  ;  and  nephritis,  associated  with  excessive  oedema.  In  each 
case,  however,  it  is  incumbent  to  carefully  consider  whether  the  special 
condition  is  rendered  more  threatening  by  the  existence  of  pregnancy, 
and  to  weigh  the  question  as  to  how  far,  for  the  time  being,  the  dan- 
gers are  likely  to  be  increased  by  the  progress  of  labor. 

Stehberger  has  proposed  extending  this  indication  to  cases  where 
the  preservation  of  the  mother's  life  is  hopeless,  but  in  which  prema- 
ture delivery  affords  a  chance  of  saving  the  life  of  the  child.* 

Operation. 

A  great  number  of  methods  have  been  proposed  with  the  view  to 
provoke  labor  prematurely.  Most  of  them,  however,  such  as  the  ad- 
ministration of  ergot,  of  quinine,  or  of  jaborandi,  the  application  of 
electricity  to  the  uterus,  the  stimulation  of  the  vagina  with  carbonic 
acid,  frictions  of  the  breasts,  and  the  like,  do  not  require  anything 
more  than  cursory  mention.  The  following  procedures  alone  possess 
any  special  claims  to  favor  : 

*  Stehberger,  "  Lex  regia  und  kiinstlichc  Friihgeburt,"  "  Arch.  f.  Gynaek.,"  Bd.  i, 
p.  465. 


THE  INDUCTION  OF  PREMATURE  LABOR. 


329 


Catheterization  of  the  Uterus. — This  method  consists  in  the  in- 
troduction of  a  catheter,  or,  better  still,  an  elastic  bougie,  between  the 
membranes  and  the  walls  of  the  uterus,  and  leaving  the  instrument  in 
situ  until  active  labor  sets  in.  In  performing  the  operation  it  is  a  good 
plan  to  place  the  patient  in  a  recumbent  posture  upon  a  hard  table, 
with  the  hips  brought  near  the  edge,  and  the  thighs  well  flexed  upon 
the  body.  Two  fingers  in  the  vagina  guide  the  point  of  the  bougie 
into  the  cervix.  The  index-finger,  passed  to  the  os  internum,  then 
follows  the  instrument,  and  as  it  enters  the  uterus  directs  it  to  one 
side  to  prevent  it  from  rupturing  the  membranes.  In  the  case  of 
primiparae,  preliminary  dilatation  of  the  cervix  may  be  secured,  if 
necessary,  by  the  use  of  a  sponge-tent  or  of  the  vaginal  douche.  The 
bougie  should  be  pushed  slowly  upward  with  the  disengaged  hand, 
and  allowed  to  follow  its  own  course,  between  the  membranes  and  the 
uterus.  To  prevent  the  instrument  from  slipping  down,  two  inches 
of  the  extremity  may  be  left  outside  the  cervix  to  find  support  against 
the  vaginal  wall.    A  retentive  tampon  is  rarely  necessary. 

The  method  is  tolerably  certain.  In  favorable  cases  labor  follows 
its  employment  in  the  course  of  a  few  hours.  Sometimes,  however, 
no  action  is  set  up  during  the  first  forty-eight  hours,  in  which  case  it 
is  well  to  resort  to  other  additional  measures.  Outside  of  unwholesome 
hospitals,  the  use  of  the  catheter  or  bougie  to  excite  labor  is  not  asso- 
ciated with  any  peculiar  risks.  The  danger  of  detaching  the  placenta 
is  not  imminent,  if  the  instrument  be  introduced  slowly,  as,  owing  to 
its  elasticity,  the  bougie  tends  to  make  its  way  around  the  placental 
margin.  In  maternity  hospitals,  however,  it  may  serve  as  a  point  of 
entry  for  miasmatic  poisons,  and  thus  be  followed  by  local  irritation 
and  puerperal  septic  affections.  Because  of  this  danger  the  solid 
bougie  is  preferable  to  the  hollow  catheter.  In  all  cases  only  a  per- 
fectly clean  and  new  instrument  should  be  used. 

Injections  between  the  Uterus  and  Ovum.— Cohen,  of  Hamburg, 
proposed  in  1848  the  separation  of  the  membranes  by  injecting  tar- 
water  through  a  long-nozzled  syringe  made  to  penetrate  about  two 
inches  within  the  uterine  cavity.  The  nozzle  was  furnished  with  a 
rounded  extremity,  and  with  openings  upon  the  side.  He  recom- 
mended that  the  injection  should  be  continued  until  a  distinct  feeling 
of  distention  was  experienced  by  the  patient,  which  sometimes  required 
the  employment  of  nearly  a  quart  of  the  fluid  (720  grammes).*  This 
plan  has  since  been  modified  by  the  substitution  of  an  elastic  catheter 
for  the  metallic  tube,  and  by  the  injection  of  a  few  ounces  of  simple 
warm  water  (98°  Fahr.)  in  place  of  the  aqua  picea.  In  case  of  failure 
with  a  single  injection,  it  has  been  recommended  to  repeat  the  pro- 
cedure. Professor  Lazarewitch  has  demonstrated  that  the  nearer  the 
irritation  is  carried  to  the  fundus  the  more  certain  and  speedy  the 

■'^  Cohen,  "Neue  Ztschr.  f.  Geburtsk.,"  Bd.  xxi,  p.  116. 


330 


OBSTETRIC  SURGERY. 


result.  He  therefore  employs  a  syringe  with  a  central  opening,  and 
passes  it  as  near  to  the  fundus  as  possible.* 

When  efficiently  performed,  the  method  possesses  the  advantage  of 
rapidly  exciting  uterine  labor-pains.  Kiinne  reports  fifteen  cases  in 
which  he  resorted  to  it  with  complete  success.  He  cautions  against 
using  force  in  injecting,  and  recommends,  as  a  means  of  avoiding  the 
passage  of  air  into  veins,  the  withdrawal  of  the  catheter,  and  its  re- 
introduction,  in  case  a  haemorrhage  should  betoken  that  the  placenta 
had  been  impinged  upon.  Others  have  employed  the  method  many 
times  with  entire  impunity.  Still,  cases  of  sudden  death  have  occurred 
during  its  use,  which  have  been  referred  to  shock,  to  air  getting  into 
the  uterine  sinuses,  and  to  rupture  of  the  uterus.  While,  perhaps, 
the  general  results  from  uterine  injections  have  not  been  less  satisfac- 
tory than  from  the  employment  of  other  measures  for  inducing  pre- 
mature labor,  the  suddenness  of  death  in  the  fatal  cases  has  had  a  deter- 
rent effect  upon  its  extended  employment. 

Rupture  of  the  Membranes.— This  is  the  oldest  of  all  the  methods 
now  in  use.  It  is  best  performed  by  means  of  a  simple  apparatus  de- 
vised by  the  Freiherr  Braun  von  Fernwald,  consisting  of  a  goose-quill 
sharpened  like  a  pen  and  nicked  upon  its  convex  surface  for  the  pas- 
sage of  a  uterine  sound.  Thus  mounted,  with  its  point  guarded  by 
the  sound,  it  can  be  introduced,  without  risk  to  the  maternal  tissues, 
through  the  cervix  to  the  ovum.  Then,  by  simply  pushing  the  quill 
upward,  the  point  is  made  to  clear  the  sound  and  effect  the  puncture 
of  the  membranes.  The  method  is  certain,  though  not  always  speedy 
in  its  action.  It  is  open  to  the  objections  which  hold  good  in  all  cases 
of  premature  discharge  of  the  amniotic  fluid.  Hopkins  recommended, 
as  a  mode  to  provide  for  the  gradual  escape  of  the  liquor  amnii,  tap- 
ping the  membranes  with  a  sound  at  a  distance  from  the  os  internum. 
Rokitansky  has  shown,  from  the  statistics  of  Braun's  clinic,  that  in 
hospital  practice  puncture  of  the  membranes  is  the  safest  means  of 
inducing  premature  labor,  diminishing  as  it  does  the  chances  of  infec- 
tion, which  is  the  chief  source  of  danger  in  all  the  measures  where 
the  irritation  is  applied  directly  to  the  inner  surface  of  the  uterus. 
Though  in  private  j^ractice  I  have  never  from  choice  selected  this 
method,  I  have  witnessed  many  cases  in  which  the  membranes  have 
ruptured  accidentally,  and  yet  have  failed  to  notice,  either  in  the  case 
of  the  mother  or  child,  the  serious  consequences  which  theory  would 
lead  us  to  apprehend.  It  is  not  adapted  for  the  higher  degrees  of 
pelvic  contraction  or  for  cases  where  speedy  delivery  is  desirable. 

Mechanical  Dilatation  of  the  Cervix.— The  dilatation  of  the  cervix 
with  sponge-tents  or  laminaria  is  rarely  resorted  to,  except  as  prepara- 
tory to  other  measures.  While  the  expansion  of  the  tent  softens  the 
cervix  and  excites  uterine  contraction,  the  effect  is  quite  frequently 
*  Lazarewitch,  "Trans,  of  the  Obstet.  Soc.  of  London,"  1868. 


THE  INDUCTION  OF  PREMATURE  LABOR. 


331 


transient.  To  be  sure,  the  action  may  be  kept  up  by  a  succession^  of 
tents  gradually  increasing  in  size,  but  such  a  plan  denudes  the  cervix 
of  its  ei)ithelium,  and  is  apt  to  lead  to  septic  infection. 

The  Barnes  dilator  is  a  most  efficient  aid  in  cases  of  induced  labor. 
As,  for  the  introduction  of  the  smallest-sized  bag,  the  cervix  requires 
to  be  sufficiently  expanded  to  permit  the  passage  of  at  least  two  fingers, 
it  is  useful  chiefly  as  an  adjuvant  to  other  plans  of  treatment.  When 
labor  has  fairly  begun,  however,  the  fluid  pressure  of  the  dilator  upon 
the  cervix  serves  to  strengthen  the  uterine  action.  When  left  in  situ, 
the  instrument  insures  the  development  of  good  pains.  It  should, 
however,  be  removed  from  time  to  time,  if  not  forcibly  expelled  into 
the  vagina,  and  carbolized  injections  should  be  employed  to  prevent 
infection.  So  soon  as  the  physiological  softening  of  the  cervix  which 
results  from  labor  has  been  effected,  rapid  dilatation  can  be  advanta- 
geously employed.  When  the  cervix  is  rigid,  the  rubber-bag  is  only 
useful  as  a  reflex  exciter  of  pains.  To  be  sure,  the  rigid  cervix  can  be 
forcibly  dilated  to  almost  any  extent  by  hydrostatic  pressure,  but, 
as  a  rule,  it  closes  down  to  its  original  dimensions  so  soon  as  the 
pressure  is  removed. 

Tarnier  has  devised  a  bag  which  can  be  passed  upward  through  the 
cervix  and  distended  in  the  lower  uterine  segment.  It  serves  to  par- 
tially detach  the  membranes,  and  excites  by  its  presence  active  uterine 
efforts.  •  Its  liability  to  rupture  is  the  most  serious  objection  to  its 
employment. 

The  Vaginal  Douche.  —  The  vaginal  douche  was  introduced  into 
practice  by  Kiwisch,  in  1846.  It  consists  in  directing  a  stream  of 
tepid  water  with  considerable  force  directly  against  the  cervix.  The 
stream  may  either  be  furnished  by  a  Davidson's  syringe,  or  a  continu- 
ous current  from  a  tube  connecting  with  a  vessel  placed  at  an  elevation 
above  the  patient  may  be  used.  The  latter  is  the  safer  method.  The 
large-sized  fountain-syringe,  made  to  hold  a  gallon  of  water,  is  a  very 
convenient  apparatus.  The  duration  of  each  injection  should  be  from 
ten  to  fifteen  minutes.  At  the  outset,  three  douches  in  the  twenty-four 
hours  suffice.  Subsequently  the  frequency  and  duration  should  de- 
pend upon  the  degree  of  action  excited  and  the  urgency  which  exists 
for  bringing  labor  to  a  close.  Twelve  are  about  the  average  number 
of  injections  required.  In  pressing  cases  they  have  been  repeated  as 
often  as  once  in  three  to  four  hours.  The  temperature  of  the  water 
employed  should  be  about  106°  Fahr. 

In  using  the  douche  the  patient  should  be  placed  across  the  bed, 
and  an  India-rubber  sheet  should  be  so  arranged  under  the  hips  as 
to  convey  into  a  vessel  beneath  the  water  as  it  escapes  from  the  vulva. 
Every  care  should  be  taken  to  avoid  the  introduction  of  air  into  the 
vagina,  and  at  the  beginning  of  each  douche  precautions  should  be 
adopted  to  aid  the  escape  of  the  fluid.    The  forcible  pressure  of 


332 


OBSTETRIC  SURGERY. 


the  stream  has  been  known  to  drive  air  contained  in  the  vagina  into 
the  cervix.  The  same  accident  has  followed  imperfection  in  the  valves 
of  the  syringe. 

The  douche  acts  by  the  warmth  of  the  water,  by  stimulation  of  the 
lower  uterine  segment,  and  by  dilatation  of  the  vagina.  After  the 
douche  has  been  continued  for  a  time,  the  latter  is  sometimes  dis- 
tended so  as  to  be  nearly  in  contact  with  the  pelvic  walls. 

The  vaginal  douche  as  a  means  of  inducing  labor  has  of  late  years 
fallen  somewhat  into  disrepute.  Its  chief  recommendation  was  the 
supposed  harmlessness  of  the  procedure — a  precious  quality,  to  which 
in  reality  it  appears,  however,  to  possess  little  claim.  Numerous  cases 
have  been  reported  where  death  has  followed  the  accidental  introduc- 
tion of  air,  and  sharp  peritoneal  symptoms,  according  to  Klein wach- 
ter,*  have  been  known  to  result  from  the  excessive  distention  of  the 
vagina.  The  dangers  referable  to  the  latter  cause  increase  with  the 
repetitions  of  the  douche.  At  present  its  employment  is  generally 
restricted  to  the  preliminary  dilatation  of  the  os,  or  to  the  sustaining 
of  the  action  of  other  measures. 

The  Vaginal  Tampon. — Braun  introduced  an  India-rubber  bag, 
furnished  with  a  tube  and  a  metal  stopcock,  which,  under  the  name 
of  the  colpeurynter,  played  a  considerable  role  in  obstetrical  practice 
some  dozen  or  more  years  ago.  When  filled  with  water  in  the  vagina, 
it  formed  a  painful  and  rather  uncertain  mode  of  inducing  labor.  It 
is  now  rarely  employed  except  in  haemorrhage  and  where  it  is  desired 
to  prevent  premature  rupture  of  the  membranes.  Care  should  be 
taken  to  only  moderately  distend  the  vagina,  and  not  to  continue  the 
pressure  for  any  lengthened  period  of  time. 

Choice  of  Methods. — From  the  foregoing  it  will  be  seen  that  no  one 
of  the  diiferent  proceedings  mentioned  is  entirely  free  from  objection. 
Aside,  however,  from  infection,  a  danger  more  especially  dreaded  in 
maternity  hospitals,  and  the  avoidable  accident  of  driving  air  into  the 
veins,  the  most  serious  difficulties  against  which  we  have  to  contend 
arise  from  the  tardy  dilatation  of  the  os  and  the  prolongation  of 
labor.  Any  of  the  methods  are  good  if  only  they  act  speedily.  It  is 
advisable,  therefore,  in  practice  to  follow  the  excellent  advice  of  Dr. 
Barnes,  and  divide  the  induction  of  premature  labor  into  two  stages, 
in  the  first  of  which  provocative,  and  in  the  second  of  which  accelera- 
tive,  measures  should  be  adopted.  In  the  former  category  should  be 
placed  the  dilatation  of  the  cervix  with  sponge-tents,  the  vaginal 
douche,  and  the  catheterization  of  the  uterus  ;  in  the  latter,  dilatation 
of  the  cervix  with  the  rubber  bags,  rupture  of  the  membranes,  and, 
in  case  of  delay,  delivery  with  forceps  or  by  version. 

The  plan  I  have  generally  followed  consists  in  beginning  in  the  af- 
ternoon with  the  vaginal  douche,  and  following  with  the  introduction 

*  Kleinwaciitku,  "Pragcr  Viertcljahrschrift,"  18*72,  Heft  i,  p.  58. 


THE  INDUCTION  OF  PREMATURE  LABOR. 


333 


of  a  solid  bougie,  to  be  left  in  the  uterus  overnight.  In  many  cases 
labor  is  excited  in  the  course  of  a  few  hours.  In  the  morning,  if  the 
process  is  delayed,  the  vaginal  douche  is  rej)eated.  There  are  few  cases 
in  which,  toward  the  end  of  the  twenty-four  hours,  the  cervix  is  not 
found  softened  and  well  lubricated  with  mucus.  The  dilators  should 
then  be  employed,  the  operator  taking  his  time,  as  permanent  dilata- 
tion is  the  object  sought  after.  If  the  membranes  come  down  well, 
the  dilator  may  be  removed  and  the  progress  of  the  case  left  to  Nat- 
ure. Often  it  is  advisable  to  adopt  the  plan  of  Dr.  Barnes,  ruptur- 
ing the  membranes  when  the  cervix  will  admit  three  or  four  fingers, 
and  then  dilating  with  the  large-sized  bag  until  the  uterus  is  opened 
fully  for  the  passage  of  the  child.  Finally,  according  to  the  condi- 
tions present,  the  physician  may  either  await  the  termination  of  the 
labor,  or  deliver  by  version  or  by  lightly  constructed  forceps. 

Care  of  the  Child. — Premature  infants  possess  slight  powers  of  re- 
sisting external  agencies.  They  should  immediately  after  birth  be 
placed  in  warm  cotton  and  kept  near  the  fire.  The  customary  baths 
should  possess  a  temperature  of  about  100°  Fahr.,  or  very  nearly  the 
temperature  of  the  amniotic  fluid.  The  chances  of  raising  premature 
infants  are  greatly  enhanced  by  feeding  them  upon  the  mother's  milk, 
which  should  be  given  by.  the  spoon  when  the  child  is  too  feeble  to 
take  the  breast.  Before  the  thirty-second  week  the  preservation  of 
the  infant's  life  depends  almost  entirely  upon  the  unremitting  watch- 
fulness and  zeal  of  a  devoted  nurse  or  mother.  In  hospitals,  where 
these  conditions  fail,  success  in  raising  very  premature  children  is  of 
rare  occurrence. 

Artificial  Abortion.  ^ 
Artificial  abortion  is  justifiable  whenever  it  offers  the  only  hope  of 
saving  the  life  of  the  mother.  The  morality  of  this  general  proposi- 
tion is  unquestioned.  It  is  not,  however,  by  any  means  easy  to  deter- 
mine in  a  S2)ecified  case  whether  the  requisite  conditions  which  render 
the  induction  of  abortion  a  duty  really  exist. 

The  principal  recognized  causes  for  the  operation  which  admit  of 
little  dispute  are  :  1.  Incarceration  of  the  prolapsed  or  retroflexed 
uterus  when  the  dislocated  organ  can  not  be  replaced.  2.  Diseases  of 
pregnancy  which  immediately  imperil  life,  and  which  have  been  vainly 
combated  by  all  the  resources  at  our  disposal.  Of  these  diseases  the 
most  prominent  is  uncontrollable  vomiting.  Exceptionally  the  indi- 
cation may  arise  in  affections  of  the  heart,  lungs,  and  kidneys,  where 
the  symptoms  are  acute  and  peculiarly  threatening. 

The  justifiability  of  abortion  is,  however,  by  no  means  so  clear 
when  the  danger  to  the  mother  first  arises  after  labor  has  actually 
begun.  This  is  specially  the  case  in  extreme  degrees  of  pelvic  con- 
traction, or  where  the  presence  of  large  tumors  renders  the  parturient 
canal  impassable,  as  in  these  cases,  by  means  of  the  Oaesarean  section, 


334 


OBSTETRIC  SURGERY. 


there  is  always  a  probability  of  saving  the  life  of  the  child^  with  a  fair 
prospect  of  preserving  the  existence  of  the  mother.  It  is  considered 
right,  under  such  circumstances,  after  a  dispassionate  and  colorless 
statement  of  the  facts,  to  leave  the  decision  to  the  mother  and  the 
friends  more  immediately  interested.  When  the  operation  is  per- 
formed for  contracted  pelvis,  the  following  figures  will  show  at  how 
late  a  period  it  may  be  undertaken  : 


With  less  than  an  inch  the  difficulties  of  inducing  abortion  increase 
to  such  a  degree  as  to  make  the  operation  rarely  advisable,  or  indeed 
even  practicable.* 

The  induction  of  abortion  is  accomplished  by  puncturing  the  mem- 
branes with  a  uterine  sound,  or  by  dilatation  of  the  cervix  with  a 
sponge-tent.  In  the  early  months  the  sponge-tent  possesses  the  ad- 
vantage of  promoting  the  expulsion  of  the  ovum  entire.  In  the  sixth 
and  seventh  months  the  same  means  are  available  that  have  been 
described  in  connection  with  the  induction- of  premature  labor. 

As  to  the  choice  of  time  when  the  operation  should  be  performed, 
opinions  differ.  Some  prefer  the  first  two  months,  on  account  of  the 
small  size  of  the  ovum,  and  the  slight  development  of  the  fetal  tufts 
at  the  decidua  serotina.  Others  wait  till  the  first  three  or  four  months 
have  expired,  as  the  diagnosis  of  pregnancy  is  then  certain,  the  execu- 
tion of  the  operation  easy,  and  the  detachment  and  expulsion  of  the 
fetal  appendages  more  complete. 


History. — Varieties  of  forceps  ;  short  forceps,  long  forceps. — Action  of  forceps. — Indica- 
tions.— Preparations. — Forceps  at  outlet. — Operation ;  introduction ;  locking ;  ti'ac- 
tions  ;  removal. — Forceps  at  brim  ;  operation. — Axis-traction  forceps. — Forceps  in 
occipito-posterior  positions ;  in  face  presentations. 

History. — In  1647  Peter  Chamberlen  speaks,  in  a  pamphlet  written 
by  himself,  of  a  discovery  made  by  his  father,  Paul  Chamberlen,  for 
saving  the  lives  of  infants  during  childbirth.  The  measure  in  the 
possession  of  the  Chamberlcns  was,  however,  withheld  from  the  pro- 

*  De  Soyue,  "  Dans  quels  cas  estc-il  indiqu6  dc  provoqucr  I'avortcraent  ?  "  Paris,  1875, 
p.  68. 


Antero-posterior  diameter  of  pelvis. 


Latest  period  for  inducing  abortion. 

Beginning  of  sixth  month. 
Beginning  of  fifth  month. 
Four  months  and  a  half. 


1^  inch. 
1 J  inch. 
1  inch. 


CHAPTER  XIX. 


FORCEPS. 


FORCEPS. 


335 


fession,  and  utilized  purely  as  a  means  of  gain.  In  the  early  part  of 
the  year  1670,  Hugh  Chamberlen,  who  enjoyed  a  great  reputation  as 
an  accoucheur,  went  to  Paris  in  the  hopes  of  finding  a  purchaser  for 
the  family  secret.  Mauriceau,  to  test  the  value  of  Chamberlen's  pre- 
tenses, suggested  that  the  latter  should  attempt  the  delivery  of  a 
woman  with  extreme  contraction  of  the  pelvis,  upon  whom  he  had 
previously  decided  to  perform  the  Caesarean  section.  Chamberlen  de- 
clared that  nothing  could  be  easier,  and  at  once,  in  a  private  room, 
set  about  the  task.  After  three  hours  of  vain  effort  he  was  obliged  to 
acknowledge  his  defeat.  The  woman  died  ;  the  negotiations  for  sale 
were  dropped  ;  and  Chamberlen  returned  with  his  secret  unrevealed  to 
England.  In  1672  Chamberlen  published  a  translation  of  Mauriceau's 
work  upon  midwifery,  in  the  preface  of  which  he  states  :  My  father, 
brothers,  and  myself  (though  none  else  in  Europe  as  I  know)  have, 
by  God's  blessing  and  our  own  industry,  attained  to  and  long  prac- 
ticed a  way  to  deliver  women  in  this  case  without  any  prejudice  to 
them  or  their  infants,  though  all  others  (being  obliged,  for  want  of 
such  an  expedient,  to  use  the  common  way)  do  or  must  endanger,  if 
not  destroy,  one  or  both  with  hooks."  In  1688  Hugh  Chamberlen 
went  to  Amsterdam  and  sold  his  secret  to  Eoenliuysen  for  a  large  sum, 
who  in  turn  disposed  of  it  to  Euysch  and  others,  and,  as  late  as  1746, 
it  was  the  rule  of  the  Medico-pharmaceutical  College,  at  Amsterdam, 
that  no  one  should  practice  midwifery  without  first  obtaining  the  se- 
cret measure,  which  was  imparted  by  their  examining  body  for  a  heavy 
money  consideration.  In  1753  Jacob  de  Vischer  and  Hugo  van  de- 
Poll,  who  had  acquired  the  secret  from  the  daughter  of  a  former  pos- 
sessor, made  it  public  property,  but  the  instrument  turned  out  to  be 
the  single-bladed  vectis.  Whatever  doubts,  however,  this  exposure 
may  have  cast  upon  the  nature  of  the  Chamberlen  secret  were  set  at 
rest,  in  1815,  by  the  discovery  in  a  former  residence  of  the  family,  in 
Woodham,  in  Essex,  of  a  chest  containing,  besides  letters  and  a  variety 
of  patterns  of  the  vectis,  a  number  of  pairs  of  forceps,  fenestrated, 
without  a  pelvic  but  with  an  excellent  cephalic  curve.  Moreover, 
Chapman,  in  a  short  treatise  upon  midwifery,  published  by  him  in 
1733,  stated  that  '^the  secret  m_entioned  by  Dr.  Chamberlen  was  the 
use  of  forceps,  now  well  known  to  the  principal  men  of  the  profession 
both  in  town  and  country."  And  two  years  later,  in  a  second  edition 
of  1*118  work,  he  published  an  engraving  of  the  instrument,  which  be- 
came known  as  Chapman's  forceps,  though  it  did  not  differ  from  the 
on^  used  by  the  Chamberlens. 

^  Since  Chapjnan's  publication,  the  modifications  made  in  the  for- 
c/eps  by  obstetrTa  practitioners  have  been  exceedingly  numerous.  In- 
deed, nearly  every  man  widely  engaged  in  midwifery  practice  finds  it 
convenient  to  possess  his  own  forceps.  With  few  exceptions,  however, 
the  various  patterns  described  by  authors  do  not  differ  materially  as 


336 


OBSTETRIC  SURGERY. 


regards  essential  principles,  but  have  each  some  peculiarity  of  con- 
struction which  fits  them  to  supplement  a  personal  defect  of  the  con- 
triver, or  to  meet  some  special  indication.  The  forceps  is  by  no  means 
a  perfect  instrument.  It  is  impossible  to  construct  it  in  such  a  way 
as  to  cover  every  need.  In  consulting  practice,  it  is  convenient  to 
possess  a  number  of  forceps  for  different  emergencies.  A  good  pair 
for  general  use  is  necessarily  a  compromise  between  conflicting  aims, 
and  requires,  for  successful  use,  experience  and  intelligence  to  correct 
its  deficiencies. 

In  selecting  forceps  it  is  well  to  bear  the  following  points  in  mind  : 
We  have  first  to  distinguish  between  the  long  and  the  short  forceps. 

Short  Forceps. — The  original  instrument  of  the  Ohamberlens  fur- 
nishes the  type  of  the  short  variety.    By  referring  to  Fig.  147,  it  will 

be  seen  that  the  Chamberlen  forceps  consisted 
of  two  levers,  made  to  cross  each  other  like 
a  pair  of  scissors,  with  short  handles,  and 
blades  diverging  Just  beyond  the  point  of 
articulation.  The  blades  were  fenestrated 
to  lighten  the  instrument,  and  to  enable  them 
to  seize  the  head  with  greater  security.  They 
were  furnished  with  a  cranial  curve,  as  has 
been  stated,  but  were  straight  when  viewed 
in  profile.  Though 
somewhat  rude  in  ap- 
pearance, they  were 
capable  of  rendering 
good  service  when  the 
head  had  once  entered 
the  pelvic  cavity. 
Smellie,  in  place  of  the  mortise  lock  of  the 
Chamberlen  forceps,  which  required  to  be  se- 
cured by  tape  or  cord,  invented  the  easily  ad- 
justed English  lock,  and  covered  the  handles 
with  wood  and  a  durable  coat  of  leather.  The 
handles  were  five  and  a  half  inches  in  length, 
and  the  blades  six  inches.  Short  forceps,  mod- 
ified somewhat  from  the  Smellie  pattern,  are 
used  by  some  practitioners  at  the  present  day. 
It  has  been  thought  an  advantage  that  they  can 
be  concealed  in  the  pocket,  and  slipped  over 
the  child's  head  without  the  knowledge  of  the 
patient  or  of  the  assistants.  Smellie  laid  great 
stress  upon  this  point,  and  says,  "As  women  \ 
are  commonly  frightened  at  the  very  name  of  an  instrument,  it  is 
advisable  to  conceal  them  as  much  as  possible  until  the  character  of 


147. — Forceps  of  Cham- 
berlen. 


-Forceps  of  Smel  - 
lie. 


FORCEPS. 


337 


the  operator  is  fully  established."  In  these  enlightened  days,  how- 
ever, secrecy  is  no  longer  advisable.  Indeed,  the  forceps  ought  never 
to  be  used  without  such  exposure  of  the  vulva  as  will  enable  the  opera- 
tor to  exercise  every  precaution  for  the  preservation  of  the  perinaeum. 

LoDg  Forceps. — Smellie  tells  us  he  found,  in  pelves  with  jutting-in 
of  the  sacrum,  that  he  could  not  push  the  handles  far  enough  back- 
ward to  include  between  the  blades  the  bulky  part  of  the  head,  which 
lay  above  the  pubes. 
He,  therefore,  to  reme- 
dy this  inconvenience, 
contrived  a  longer  pair, 
curved  on  one  side,  and 
convex  on  the  other. 
Thus,  at  an  early  period 
the  necessity  for  long 
forceps  was  experi- 
enced. Smellie  was 
deeply  impressed,  how- 
ever, with  the  dangers 
of  high  forceps  opera- 
tions, and  sought  to  di- 
minish the  risks  inci- 
dental to  them  by  mak- 
ing the  handles  short  to 
free  himself,  as  he  said, 
from  the  temptation  of  ll't, 
using  too  great  force. 

Levret,  on  the  con- 
trary, contemporane- 
ously with  Smellie,  con- 
verted the  forceps  of 
Chapman  into  a  power- 
ful tractor  and  compres- 
sor. He  retained  the 
iron  handles,  but  rough- 
ened the  surfaces,  and 

made  them  slightly  convex,  to  adapt  them  to  the  palms  of  the  hand. 
The  articulation  was  effected  by  means  of  a  pivot  and  a  mortise.  The 
chief  peculiarities,  however,  consisted  in  the  weight  and  the  length 
of  the  instrument  and  in  the  extent  of  the  pelvic  curve.  So  far  from 
these  features  proving  objectionable,  they  have  been  substantially 
retained  in  modern  French  instruments. 

The  forceps  of  Smellie  and  Levret  are  the  two  type-forms  from 
which  are  derived  the  great  number  of  the  models  in  vogue  at  the 
present  day. 

22 


Fig,  149. — Levret's  forceps. 


338 


OBSTETRIC  SURGERY. 


The  Naegele  forceps,  extensively  used  in  Germany,  in  its  main 
features  resembles  the  instrument  of  Smellie.    It  is,  however,  two 

inches  longer,  and  there  is  less  dis- 
proportion between  the  length  of 
the  handles  and  the  blades.  The 
upper  part  of  the  handles  is  fur- 
nished with  transverse  shoulders, 
hollowed  out  for  the  index  and 
middle  fingers  of  the  hand  which 
exerts  the  traction  force.  The  lock 
is  that  of  Bruninghausen,  and  con- 
sists of  a  pivot,  surmounted  by  a 
flat  button,  which  fits  into  a  notch 
upon  the  opposing  blade. 

The  Simpson  forceps  possesses 
a  relatively  short  handle,  with 
transverse  shoulders,  and  indenta- 
tions for  the  fingers  of  the  under 
hand.  The  English  lock  is  im- 
proved by  the  addition  of  knees  or 
projections  to  diminish  its  mobili- 
ty. The  cephalic  curve,  in  place 
of  starting  at  the  lock,  is  carried 
away  two  and  three  eighths  inches  by  straight,  parallel  shanks,  an 
arrangement  which  makes  it  possible  to  lock  the  instrument  outside 
the  vulva  even  when  applied  to  the  head  at  the  brim,  and  which 
enables  the  operator  to  bring  the  head  to  the  floor  of  the  pelvis 
without  placing  the  vulva  upon  the  stretch.  The  pelvic  curve  does 
not  exceed  one  inch  and  a  half.  I  have  been  in  the  habit  of  recom- 
mending this  forceps  to  my  classes  of  medical  students  on  account 


Fio.  150. — Naegele's  forceps. 


Fig.  151. — Simpson's  forceps. 

of  the  ease  with  which  it  can  be  applied,  its  solidity,  and  the  slight 
markings  it  leaves,  under  ordinary  circumstances,  uj)on  the  child's 
head.  It  is,  however,  defective  in  compressive  power,  when  such 
action  is  necessary.* 

*  The  instrument  makers  of  this  city  are  accustomed  to  make  for  mc  an  instrument 
exactly  copied  from  a  pair  of  forceps  brought  by  me  from  Edinburgh  in  1865,    Many  of 


FORCEPS. 


339 


The  forceps  of  Hodge,  of  Wallace,  and  of  White,  are  extensively 
used  in  this  country.  Like  those  of  French  make,  they  have  metal 
handles,  and  a  lock  composed  of  a  movable  pivot,  which  slips  into  a 
notch  at  the  moment  of  adjustment.  They  are,  however,  much 
lighter  and  of  more  graceful  outline.    The  shanks  are  long  and  su- 


perimposed. The  blades  are  provided  with  wide  fenestrse,  through 
which  the  parietal  bosses  are  intended  to  project.  I  have  tried  each 
of  these  instruments,  and,  though  I  cling  to  Simpson's  forceps  from 
habit,  have  found  them  extremely  serviceable. 

Finally,  in  choosing  forceps,  it  is  well  to  remember  that,  if  there 
are  none  which  are  absolutely  perfect,  there  are  few  which  are  really 
poor.  Objectionable  features  are  very  short  handles  and  thin,  springy 
blades,  with  sharp-cutting  edges.  A  good  pair  of  long  forceps  ren- 
ders the  possession  of  short  forceps  a  superfluous  luxury. 

Action  of  the  Forceps. — The  forceps  is  primarily  and  essentially  a 
tractor.  When  properly  adjusted,  it  serves  as  a  handle  by  means  of 
which  the  head  can  be  withdrawn  from  the  parturient  canal.  Many 
excellent  operators  are  in  the  habit  of  combining  with  direct  traction 
a  side-to-side  swaying  of  the  forceps-handles  with  a  view  of  determin- 
ing the  alternate  descent  of  the  lateral  surfaces  of  the  cranial  vault. 
No  doubt  these  so-called  pendulum  movements  increase  the  extractive 
power  of  the  forceps.  The  increase  is,  however,  obtained  at  the  expense 
of  the  maternal  tissues.  They  should,  therefore,  be  discountenanced. 
As  to  the  efficiency  of  direct  tractions,  I  am  able  to  speak  from  ex- 
perience. At  first  insisted  upon  by  the  Vienna  school,  they  have 
found  warm  advocates  in  Matthews  Duncan,*  of  London,  and  Albert 
Smith,!  of  Philadelphia. 

The  crossing  of  the  forceps  at  the  lock  renders  it  impossible  to 

the  forceps  bearing  Simpson's  name  in  this  country  have  only  a  faint  resemblance  to  the 
original  model. 

*  Duncan,  "  Against  the  Pendulum  Movement  in  working  the  Midwifery  Forceps," 
"Trans,  of  the  Obstet.  Soc.  of  Edinburgh,"  vol.  iv,  p.  195. 

f  Smith,  "  The  Pendulum  Leverage  of  Obstetric  Forceps,"  "  Trans,  of  the  Am.  Gy- 
naec.  Soc,"  vol.  iii,  p.  235. 


Fig.  152. — Hodge's  forceps. 


340 


OBSTETRIC  SURGERY. 


resort  to  traction  without,  at  the  same  time,  exercising  compression 
upon  the  child's  head.  When  the  forceps  is  applied  laterally  over 
the  parietal  bones,  moderate  pressure  is  harmless  to  the  child,  and 
undoubtedly  facilitates  in  some  degree  the  act  of  delivery.  When 
the  head  is  high  in  the  pelvis  before  rotation  is  completed,  the  lateral 
application  is  rarely  possible.  If  the  forceps  is  applied  obliquely  with 
one  blade  over  the  side  of  the  brow,  and  the  other  over  the  side  of  the 
occiput,  bulging  takes  place  in  the  opposite  oblique  diameter — a  result 
which  tends  to  retard  rather  than  to  aid  extraction.  N^evertheless, 
even  at  the  brim  some  compressive  force  is  necessary  to  seize  the  head 
solidly,  and  to  avoid  slipping  of  the  blades. 

When  the  blades  of  the  forceps  are  introduced  within  the  uterus, 
contractions  are  apt  to  be  excited.  This  so-called  dynamic  influence, 
though  an  ancillary  property  of  the  instrument,  is  often  of  consider- 
able service  in  aiding  delivery. 

Indications. — It  would  be  an  unprofitable  undertaking  to  enumerate 
all  the  conditions  which  render  forceps  advisable.  The  indications  for 
their  use  may  be  summed  up  in  two  general  propositions.  The  forceps 
is  applicable — 1.  In  cases  where  the  ordinary  forces  operative  during 
labor  are  insufficient  to  overcome  the  obstacles  to  delivery  ;  2.  In  cases 
where  speedy  delivery  is  demanded  in  the  interest  of  either  mother  or 
child. 

Both  these  propositions  are,  however,  subject  to  the  limitation 
that,  in  the  selection  of  the  mode  of  delivery,  choice  should  be  made 
specially  with  reference  to  the  maternal  safety.  Fortunately,  in  the 
great  proportion  of  cases  the  interests  of  both  mother  and  child  are 
identical. 

Preparations  for  Forceps  Deliveries. — When  it  has  been  decided  to 
deliver  by  forceps,  it  is  a  good  plan  always  to  place  the  patient  cross- 
wise in  bed,  with  the  head  raised  by  a  pillow,  and  with  the  hips  well 
over  the  edge  of  the  bed.  To  be  sure,  many  prefer,  in  simple  cases,  to 
disturb  the  patient  as  little  as  possible,  and  pride  themselves  upon  being 
able  to  slip  in  the  forceps  and  deliver  without  the  seeming  of  an  opera- 
tive procedure.  This  trifling  advantage  is,  however,  more  than  coun- 
terbalanced by  the  increased  risk  of  injuring  the  vulva  and  perinseum, 
when  the  operator  is  compelled  to  assume  a  constrained  or  awkward 
position. 

In  this  country,  as  in  France  and  Germany,  it  is  customary  to 
place  the  patient  upon  her  back,  whereas  in  England  she  is  made  to 
lie  upon  her  left  side.  The  difference  is  not  material.  In  the  descrip- 
tion to  follow  it  will  be  assumed  that  the  dorsal  position  is  the  only 
one  likely  to  be  selected. 

At  the  beginning  it  is  well,  in  most  cases,  to  bring  the  patient  well 
under  the  influence  of  an  anaesthetic.  This  I  am  accustomed  to  do 
before  changing  the  patient's  position.    In  easy  cases  the  accoucheur 


FORCEPS. 


341 


can  administer  the  anaesthetic  before  operating,  and  then  leave  the  con- 
tinuance of  the  chloroform-  or  ether-giving  to  any  intelligent  bystander 
who  acts  under  his  supervision.  In  difficult  cases,  however,  it  is  better 
to  send  for  a  skilled  assistant  who  is  capable  of  taking  entire  charge  of 
the  anaesthesia,  that  the  operator's  attention  may  not  be  diverted  from 
the  work  he  has  in  hand. 

Before  applpng  the  forceps  care  should  be  taken  to  ascertain  the 
position  of  the  head,  and  to  make  sure  that  the  membranes  have  freely 
ruptured.  Forceps  applied  directly  to  the  membranes  might  do  harm 
by  causing  a  premature  detachment  of  the  placenta.  The  position  of 
the  OS  and  the  degree  of  its  dilatation  should  likewise  be  determined. 
In  excessive  anteversion  the  head  sometimes  bulges  out  the  anterior 
wall  of  the  cervix,  and  thins  the  cervical  tissues  to  such  an  extent  that 
the  sutures,  the  fontanelle,  and  contour  of  the  head,  can  be  distinctly 
felt,  as  though  the  head  had  entered  uncovered  into  the  vagina ; 
whereas,  in  fact,  the  undilated  os  is  situated  high  up,  and  with  care 
may  be  found  looking  backward  in  the  direction  of  the  sacrum.  It  is 
only  necessary  to  indicate  the  possibility  of  such  a  source  of  error  to 
insure  the  caution  necessary  for  the  avoidance  of  forceps  applications 
to  the  cervix. 

As  a  preliminary  to  all  obstetrical  operations,  both  bladder  and 
rectum  should  be  emptied.  The  blades  of  the  forceps  should  be 
dipped  in  warm  water  to  remove  the  chill  from  the  steel,  and  should 
be  smeared  with  some  oily  substance  to  reduce  to  the  minimum  the 
friction  produced  by  their  passage  into  the  utero- vaginal  canal. 

Practically  it  is  important  to  distinguish  between  forceps  opera- 
tions at  the  brim  and  those  conducted  after  the  head  has  entered  the 
cavity  of  the  pelvis.  The  latter  are  simple,  safe,  and  easy  of  accom- 
plishment, requiring  only  skill  in  the  management  of  the  perinaeum  ; 
while  the  former  belong  in  the  category  of  capital  operations,  and  call 
for  a  large  degree  of  patience,  experience,  and  obstetrical  tact  to  bring 
to  a  successful  issue. 

Forceps  at  the  Pelvic  Outlet. — The  special  indications  for  for- 
ceps when  the  head  is  low  in  the  pelvis  are  so-called  rigidity  of  the 
perinaeum,  stenosis  of  the  vaginal  orifice,  and  conditions  demanding 
speedy  delivery. 

The  condition  termed  rigidity  of  the  perinaeum  is  usually  the  sign 
of  failing  uterine  action.  So  long  as  the  labor-pains  are  good,  the  ex- 
ternal parts  progressively  soften  and  relax  in  preparation  for  the  ad- 
vancing head.  If  after  the  head  reaches  the  floor  of  the  pelvis  the 
pains  lose  their  expulsive  character,  the  perinaeum  may  be  rigid  simply 
because  the  ordinary  physiological  forces  which  induce  softening  are 
absent,  or,  in  case  softening  has  already  begun,  the  perinaeum  may 
become  rigid  from  the  sustained  pressure  to  which  it  is  subjected. 
In  either  contingency  intermittent  tractions  made  with  forceps,  in 


342 


OBSTETRIC  SURGERY. 


imitation  of  the  natural  mechanism,  is  the  speediest  and  safest  method 
of  overcoming  the  resistance  of  the  soft  parts. 

Stenosis  of  the  vulva  is  sometimes  the  result  of  old  cicatrices. 
Oftener  it  is  found  where  there  is  faulty  direction  of  the  child's  head, 
the  vertex  bulging  the  perinaeum  in  place  of  serving  as  a  dilating 
wedge  to  the  vulval  orifice.  The  danger  of  central  perforation  of  the 
perinaeum  is  best  averted  by  applying  forceps  and  bringing  the  occi- 
put well  forward  under  the  arch  of  the  pubes.  The  commonest  condi- 
tions demanding  speedy  delivery  are  convulsions,  exhaustion,  and  fe- 
brile disturbances  in  the  mother,  and  dangers  threatening  the  life  of 
the  child.  It  is,  however,  of  great  importance  to  keep  in  mind  the 
relation  that  the  prolongation  of  the  second  stage  of  labor  bears  to 
these  very  dangers.  So  long  as  the  head  advances  through  the  par- 
turient canal  by  regular  progression,  the  vagina  pours  out  an  abundant 
secretion  of  mucus  and  relaxation  takes  place.  If  the  advance  of  the 
head  is  arrested  from  the  dying  out  of  the  pains,  or  from  other  causes, 
the  continuous  pressure  exercised  by  the  head  upon  the  soft  parts  pro- 
duces venous  stasis,  oedema,  disappearance  of  the  secretion,  and  final- 
ly inflammatory  infiltration.  The  genitals  become  therefore  hot,  dry, 
swollen,  and  friable,  the  intensity  of  the  symptoms  depending  upon 
the  more  or  less  close  adaptation  of  the  head  to  the  bony  walls  of  the 
pelvic  cavity.  It  is  easy  to  understand  that  with  these  conditions  the 
temperature  rises  and  the  pulse  becomes  frequent ;  if  the  urethra  is 
compressed,  retention  of  urine  with  convulsions  may  follow ;  while,  as 
after-results,  we  may  have  phlegmasiae  extending  to  the  pelvic  cellular 
tissue  and  thence  to  the  peritonaeum.  Pressure  too  long  continued 
can  produce  necrosis,  and,  as  sloughing  occurs,  vesico-  and  recto- 
vaginal fistulae.  At  the  same  time  there  is  reciprocal  pressure  exer- 
cised by  the  bony  walls  upon  the  child's  head,  and  close  retraction  of 
the  uterus  upon  the  foetus.  The  first  cause  may  lead  to  retarded  heart- 
action  and  intra-cranial  extravasations  of  blood ;  while  the  second  is 
a  fruitful  source  of  asphyxia,  owing  to  the  diminution  of  the  maternal 
blood-currents  which  circulate  through  the  placenta. 

In  view  of  the  foregoing,  it  will  be  seen  that  forceps  is  not  alone 
indicated  in  the  presence  of  perils  fully  developed,  but  is  of  still 
greater  service  as  a  prophylactic  against  the  dangers  of  an  unduly 
lengthened  second  stage. 

It  is  in  vain  to  lay  down  well-defined  rules  as  to  the  precise  time 
at  which  the  forceps  should  be  applied.  Formerly  it  was  advised  to 
wait  for  the  advent  of  a  thin,  reddish-brown  discharge.  As  the  latter 
simply  consists  of  serum  commingled  with  blood  from  overstrained 
capillaries,  it  furnishes  a  sign  that  delivery  has  been  delayed  too  long. 
Some  counsel  applying  forceps  two  hours  after  the  completion  of  the 
first  stage  of  labor,  and  proclaim  longer  waiting  a  useless  barbarity. 
Clearly,  however,  it  is  not  so  much  the  length  of  the  second  stage  of 


FORCEPS. 


343 


labor  wliicli  furnishes  tlie  indication  for  forceps,  as  the  degree  of  the 
reciprocal  pressure  exercised  between  the  head  and  the  pelvis.  A  val- 
uable index  to  this  pressure  is  furnished  by  the  caput  succedaneum. 
In  the  second  stage,  a  scalp  tumor  of  large  circumference  can  only  be 
produced  by  the  circle  of  the  bony  pelvis.  Such  a  tumor,  increasing 
in  size,  without  any  eyidence  of  progress  in  the  delivery,  is  a  signifi- 
cant evidence  of  pressul-e,  and  furnishes,  therefore,  the  most  reliable 
indication  for  forceps. 

Whether  the  ease  with  which  forceps  can  be  applied  at  the  outlet 
and  the  safety  which  attends  its  employment  justify  its  use  as  a 


Fig.  153.— Introduction  of  blades. 


means  of  saving  the  physician's  time,  or  the  patient  from  an  addi- 
tional half-hour  of  suffering,  are  questions  which  are  at  least  de- 
batable. I  can  only  say  that,  with  increasing  experience,  my  own 
practice  has  grown  more  and  more  conservative,  and  my  own  belief 
is  that  true  wisdom  requires  us  to  abstain  from  even  trivial  oper- 
ations so  long  as  Nature  is  able  to  do  her  work  without  our  assist- 
ance. 


344 


OBSTETRIC  SURGERY. 


The  operation  consists  of  four  acts,  viz. :  1.  Introduction  of  the 
blades ;  2.  Locking ;  3.  Tractions  ;  4.  Removal  of  the  instrument. 

Introduction  of  Blades. — In  introducing  the  forceps,  each  blade, 
if  a  long  one  with  pronounced  pelvic  curve,  should  be  seized  like  a 
pen  near  the  lock,  and  should  be  held  nearly  vertically,  with  the  ex- 
tremity in  correspondence  with  the  slit-like  opening  of  the  vulva.  In 
the  Simpson  forceps,  which  possesses  only  a*  moderate  pelvic  curve, 
the  handle  should  be  lightly  grasped  in  the  half  hand,  and  held  at 
the  outset  nearly  parallel  to  Poupart's  ligament.  Owing  to  the  ar- 
rangement of  the  lock,  the  left  blade  should  be  passed  first.  The 
handle  should  accordingly  be  held  in  the  right  hand,  while  two  or 
three  fingers  of  the  left  hand,  inserted  between  the  head  and  the 
vagina,  serve  to  guide  and  guard  the  point  during  its  introduction. 
The  passage  of  the  blade  should  take  place  only  during  the  intervals 
between  the  pains.  It  is  customary  to  pass  each  blade  at  first  oppo- 
site the  sacro-iliac  articulation,  and  then  to  change  the  direction  as 
required,  after  the  point  has  reached  the  linea  terminalis. 

In  introducing  the  forceps-blades,  the  two  curves  of  the  instrument 
should  be  borne  in  mind.  By  directing  the  handle  toward  the  thigh 
of  the  mother  which  corresponds  to  the  blade,  the  latter  is  made  to 
glide  over  the  convex  surface  of  the  child's  head ;  by  sinking  the 
handle,  the  pelvic  curve  follows  the  axis  of  the  pelvis.  The  two  move- 
ments should  be  made  slowly,  but  simultaneously,  and  under  the  guid- 
ance of  the  inserted  fingers.    But  slight  force  is  necessary.   The  point 


Fig.  154. — Blade  adjusted  to  the  head  at  outlet. 


of  the  blade  should  impinge  rather  upon  the  fingers  than  upon  the 
child's  head.  When  the  left  blade  is  in  place,  the  handle  should  be 
lowered  and  intrusted  to  an  assistant.    The  right  should  be  intro- 


FORCEPS. 


345 


duced  on  the  right  side,  under  fche  guidance  of  two  to  three  fingers  of 
the  right  hand,  in  accordance  with  the  same  general  rules. 

The  cephalic  curve  of  the  forceps  is  intended  to  correspond  to  the 
lateral  surfaces  of  the  child's  head.  When  the  rotation  of  the  occiput 
under  the  symphysis  is  complete,  it  is  only  necessary  to  sink  the  han- 
dles to  make  the  blades  assume  the  natural  position  over  the  parietal 
bosses.  If  the  head  is  still  in  an  oblique  diameter,  the  forceps  should 
be  applied  in  the  opposite  oblique  diameter.  When,  therefore,  the  oc- 
ciput is  left  anterior,  the  left  blade  should  be  allowed  to  remain  oppo- 
site the  sacro-iliac  articulation,  while  the  right  blade,  by  sinking  and  at 
the  same  time  rotating  the  handle,  is  swept  forward  to  the  right  ace- 
tabulum. If  the  head  is  right  anterior,  the  left  blade  is  at  once  swept 
forward  toward  the  left  acetabulum,  while  the  riglit  blade  is  allowed 
to  remain  opposite  the  sacro-iliac  articulation.  If  the  sagittal  suture 
occupies  the  transverse  diameter,  the  forceps  should  be  applied  in  the 
oblique  diameter  of  the  same  name  as  the  side  toward  which  the  fore- 
head is  turned.  This  is  best  accomplished  by  first  applying  the  forceps 
in  the  usual  way ;  then,  leaving  the  occipital  blade  in  the  excavation  to 
the  side  of  the  promontory,  with  the  guiding  fingers  inserted  into  the 
vagina,  direct  the  frontal  blade  forward  toward  the  acetabulum.  Dur- 
ing this  manoeuvre  the  handle  should  be  held  loosely.  The  forceps 
will  seize  the  head  very  nearly  between  the  anterior  frontal  and  the 
opposite  posterior  parietal  protuberance.  The  direct  application  of 
the  forceps  to  the  sides  of  the  head,  with  one  blade  beneath  the  sym- 
physis and  the  other  opposite  the  promontory,  is  sometimes  practica- 
ble, but  is  undeserving  of  commendation.* 

Locking. — When  the  occiput  is  rotated  to  the  front,  and  the  blades 
are  applied  to  the  sides  of  the  head,  locking  is  a  very  simple  matter. 
The  handles  should  be  grasped  in  the  full  hand,  with  the  thumbs 
directed  upward.  Coaptation  is  secured  by  slight  movements  of  the 
blades  as  the  operator  sinks  the  handles  downward. 

W^hen  the  head  is  transverse  it  is  often,  on  the  contrary,  difficult 
to  bring  the  separate  parts  of  the  lock  in  apposition.  Under  such 
circumstances  no  force  should  be  used,  but  the  blades  should  be  with- 
drawn a  little,  and  the  attempt  made  to  adjust  the  lock  by  gentle 
movements  in  reintroducing  them. 

After  locking,  a  tentative  traction  should  be  made  to  ascertain 
whether  the  head  is  seized  securely.    In  bringing  the  blades  together, 
some  caution  should  be  observed  lest  the  hair  of  the  pubes,  or  the 
labia,  become  included. 

*  The  application  of  the  forceps  to  the  sides  of  the  pelvis,  without  reference  to  the 
position  of  the  child's  head,  has  many  warm  advocates.  That  the  head  can  be  delivered 
in  this  way  is  beyond  all  question.  These  so-called  direct  applications  I  practiced  exclu- 
sively for  some  years,  and  it  was  only  gradually  that  I  became  convinced  of  the  superi- 
ority of  the  methods  the  description  of  which  has  been  given. 


346 


OBSTETRIC  SURGERY. 


Tractions. — The  instrument  should  be  seized  with  the  right  or 
stronger  hand,  with  the  back  of  the  hand  turned  upward.    In  forceps 


Fig.  155. — Method  of  making  tractions. 


provided  with  transverse  shoulders,  the  index-finger  should  be  placed 
over  one  shoulder,  and  the  remaining  fingers  over  the  other.  The 
left  hand,  with  the  palm  upward,  seizes  the  handles  from  below  and 
aids  in  extraction.  When  the  handles  are  far  apart,  the  index-finger 
of  the  left  hand  should  be  introduced  into  the  vagina  from  time  to 
time,  to  determine  the  position  of  the  forceps-blades,  and  to  estimate 
the  amount  of  pressure  upon  the  child's  head  during  tractions. 

Steady  tractions  are  preferable  to  pendulum  or  rotary  ones.  Trac- 
tions are  most  effective  when  made  during  a  pain.  This  is  si^ecially 
the  case  when  the  rotation  of  the  head  is  incomplete.  However,  in  the 
absence  of  pains,  it  is  often  necessary  to  use  the  forceps  as  a  substitute 
for,  instead  of  a  reenforcement  of,  the  propulsive  action  of  the  uterus. 
Pressure  through  the  abdominal  walls  upon  the  uterus,  made  by  a 
skilled  assistant  during  tractions,  is  here,  as  in  other  obstetrical  opera- 
tions, an  adjuvant  of  great  value.    Tractions  should  not  be  too  pro- 


FORCEPS. 


347 


longed.  When  not  made  in  unison  with  the  pains,  they  should  not 
exceed  one  to  two  minutes  in  duration.  The  head  should  tlien  be 
allowed  to  recede.  Haste  in  delivery  exposes  the  patient  to  the  dan- 
gers of  laceration  and  post-partu7n  haemorrhage.  The  alternate  de- 
scent and  recession  of  the  head  soften  the  external  parts,  and  are  the 
best  means  of  overcoming  rigidity.  As  the  head  advances,  time  should 
be  given  for  the  uterus  to  retract  upon  its  contents,  for,  when  the 
pains  are  deficient,  retraction  after  the  sudden  emptying  of  the  uterus 
is  apt  to  be  imperfect  or  of  short  duration. 

Tractions  should  at  first  be  made  downward,  until  the  head  has 
descended  below  the  symphysis  pubis  ;  they  should  then  be  made  in  an 
horizontal  direction  until  the  occiput  appears  at  the  vulva.  When  in 
doubt  about  the  direction,  the  handles  should  be  held  loosely  during 
a  pain,  to  serve  as  an  index  of  the  proper  line  of  traction.  If  rotation 
has  not  previously  taken  place,  it  may  be  aided  by  the  forceps,  though 
rotation  usually  occurs  spontaneously  as  the  head  descends.  If  the 
head  was  transverse,  the  forceps  requires  to  be  readjusted  after  rota- 
tion, either  by  removing  it  and  then  reapplying  it,  or  by  sinking  the 
handle  of  the  posterior  blade  and  raising  the  handle  of  the  anterior  one. 

AVhen  the  parietal  bosses  are  in  the  act  of  passing  through  the 
vulva,  tractions  should  no  longer  be  made  during  the  pains.  The 


Fio.  156. — Position  of  operator  when  head  is  on  peringeum. 


348 


OBSTETRIC  SURGERY. 


operator  should  stand  to  the  right  of  the  patient,  and  seize  the  handles 
in  the  left  hand.  During  the  intervals  of  a  pain,  by  alternately  sink- 
ing and  raising  the  liandles,  the  perinseum  and  vulva  can  be  gradually 
dilated.  So  soon  as  the  convexity  of  the  perinasum  is  marked,  and 
the  parietal  bosses  press  upon  the  commissure,  it  is  better  to  sink  the 
handles  during  a  pain,  so  as  to  flex  the  head  to  its  greatest  extent,  and 
cause  the  vertex  to  present.  When  the  vulva  is  sufficiently  dilated,  it 
is  only  necessary  to  raise  the  handles  toward  the  abdomen  to  complete 
the  extrusion  of  the  head,  and  finish  the  delivery. 

Removal. — Although  not  generally  recommended,  it  is  always  my 
custom  to  remove  the  forceps  so  soon  as  the  chin  can  be  reached  by  the 
index-finger  introduced  into  the  rectum.  The  extrusion  of  the  head, 
if  it  does  not  occur  spontaneously,  can  then  be  easily  effected,  and  the 
blades  of  the  forceps,  though  of  no  great  thickness,  still  add  something 
to  the  distention  of  the  vulva.  The  removal  is  accomplished  by  un- 
locking and  reversing  the  direction  the  handles  followed  in  their  intro- 
duction. To  avoid  compressing  the  soft  parts  against  the  rami  of  the 
pubes,  I  am  accustomed  to  place  two  fingers  of  the  unemployed 
hand  upon  the  upper  border  of  the  blade,  and  use  them  as  a  fulcrum 
around  which  the  blade  should  be  rotated. 

Forceps  at  the  Brim. — The  safe  conduct  of  the  head  through  the 
pelvic  brim  by  means  of  the  forceps  is  an  achievement  which  requires 
an  accurate  appreciation  of  the  dangers  to  be  avoided  and  the  difficul- 
ties to  be  overcome.  The  forceps  as  a  means  of  accelerating  delivery 
is  sometimes  called  for  when  the  head  is  at  the  brim  in  cases  of  acci- 
dental haemorrhage,  of  placenta  praevia,  of  eclampsia,  of  pelvic  ob- 
struction, and  in  failure  of  uterine  pains. 

So  long,  indeed,  as  the  head  is  movable  at  the  brim,  and  version  is 
practicable,  the  latter  operation  furnishes  the  safer  mode  of  delivery. 
After  the  waters  have  drained  away,  and  retraction  of  the  uterus  ren- 
ders version  impossible,  a  tentative  application  of  the  forceps  may  be 
made  to  test  the  adaptability  of  the  head  to  the  pelvic  canal.  Persist- 
ent attempts  to  drag  the  head  into  the  pelvis  by  brute  force,  after 
moderate  tractions  have  failed  to  effect  an  advance,  should  be  regarded 
as  criminal,  exposing  as  they  do  the  maternal  tissues  unavailingly  to 
injuries  which  are  always  serious,  and  which  may  prove  fatal. 

When,  however,  the  head  has  become  fixed,  which  does  not  occur 
until  after  the  engagement  of  its  largest  circumference,  the  difficulties 
of  forceps  operations  are  greatly  diminished.  Still,  dangers  to  the 
mother  arise  from  the  fact  that  the  blades  have  to  be  passed  into  the 
lower  segment  of  the  uterus,  where,  owing  to  the  extreme  vulnerability 
of  tlie  uterine  tissues,  lesions  are  only  to  be  avoided  by  the  patient 
carrying  out  of  a  multitude  of  precautionary  measures  ;  to  the  child, 
from  the  rarity  of  the  occasions  whicli  permit  the  blades  to  be  applied 
to  the  sides  of  the  head,  to  which  the  cephalic  curve  is  alone  adapted. 


FORCEPS. 


349 


Operation. — In  introducing  the  forceps,  the  tips  of  the  fingers  of 
the  guiding  hand  should  be  inserted  between  the  child's  head  and  the 
cervix.  In  this  way  we  insure  the  entrance  of  the  extremities  of  the 
blades  into  the  uterus  in  place  of  into  the  cul-de-sac  of  the  vagina.  It 
is  generally  customary  to  apply  the  forceps  to  the  sides  of  the  pelvis, 
without  reference  to  the  position  of  the  child's  head.  As  a  rule, 
under  the  conditions  mentioned,  the  head  will  be  found  to  have 
been  seized  obliquely — i.  e.,  with  the  posterior  blade  over  the  parietal 
boss,  and  the  anterior  blade  near  the  coronal  suture.  Thus  applied, 
close  approximation  of  the  handles  is  impossible,  and  the  tips  are 


Fig.  157.— Forceps  applied  to  head  at  brim. 


correspondingly  separated  from  one  another.  Considerable  compres- 
sion of  the  handles  is  necessary,  therefore,  to  prevent  the  instrument 
from  slipping,  the  degree  of  pressure  depending  naturally  upon  the 
extractive  force  requisite  to  advance  the  head.  The  adjustment  of 
the  lock  often  requires  considerable  patience,  and  sometimes  the 
exercise  of  moderate  force  is  necessary  to  bring  the  parts  i»nto  juxta- 
position. 

Even  when  the  instrument  has  been  ai^plied  according  to  the 
strict  rules  of  art,  it  will  be  found  not  infrequently  that  the  upper 
border  of  the  anterior  and  the  lower  border  of  the  posterior  blade  will 
project  beyond  the  tissues  of  the  scalp,  and,  unless  managed  with  care, 
the  exposed  edges  are  liable  during  extraction  to  cut  deeply  into  the 
soft  structures  of  the  parturient  canal. 


350 


OBSTETRIC  SURGERY. 


When  the  cervix  is  only  partially  dilated,  the  forceps  should  be  em- 
ployed, not  as  an  extractive  instrument,  but  simply  to  bring  the  head 
into  the  cervical  canal  to  act  as  a  dilating  wedge,  by  means  of  which 
the  gradual  and  safe  expansion  of  the  os  may  be  accomplished.  If  the 
head  be  made  to  descend  and  then  allowed  to  re- 
cede at  short  intervals  between  the  pains,  in  time 
the  cervix  will  be  found  to  soften  and  yield  ia 
the  same  manner  as  a  rigid  perinaeum  ;  whereas 
the  resistance  of  an  undilated  cervix  can  only  be 
overcome,  when  violent  tractions  are  made,  by 
the  jDroduction  of  lacerations  extending  to,  or 
even  above,  the  vaginal  junction.  In  seeking  to 
effect  dilatation  of  the  cervix  through  the  forceps, 
the  utmost  caution  should,  however,  be  observed. 
At  short  intervals  the  finger  should  be  slipped 
into  the  vagina  to  note  whether  the  tension  of 
the  cervix  is  raised  during  tractions  to  danger- 
ous proportions.  Especial  attention  should  be 
paid  to  the  condition  of  the  parts  during  a  pain, 
as,  when  the  uterus  contracts,  the  os  externum, 
which  previously  was  soft  and  dilatable,  frequent- 
ly forms  a  sharp,  resistant  border. 

Dr.  I.  E.  Taylor  has  devised  a  long,  narrow- 
bladed  pair  of  forceps,  capable  of  introduction 
through  a  cervix  measuring  one  and  a  half  inch 
in  diameter,  which  he  has  used  with  advantage 
in  the  manner  above  described  at  a  very  early 
stage  of  labor. 

In  cases  where  it  is  necessary  to  expedite  de- 
livery, the  resistance  of  the  incompletely  dilated 
OS  may  be  overcome  by  a  number  of  incisions 
about  one  fourth  of  an  inch  in  depth,  made  with 
a  blunt-pointed  bistoury  passed  between  the  cer- 
vix and  the  child's  head.  It  is  very  rare,  how- 
ever, that  this  otherwise  trivial  operation  is  really 
called  for. 

In  drawing  the  head  through  the  superior 
strait,  the  tractions  should  be  made,  as  nearly 
as  the  perinaeum  will  permit,  vertically  down- 
ward. In  doing  this,  however,  care  must  be  taken 
lest  the  pelvic  curve  be  brought  so  far  forward 
above  the  symphysis  pubis  as  to  subject  the  ma- 
ternal tissues  to  injurious  pressure.  On  the  other  hand,  it  is  nec- 
essary not  to  prematurely  raise  the  handles  of  the  forceps,  as,  in  that 
case,  tlic  head  is  simply  crowded  forcibly  against  the  anterior  pel- 


Fio.  158. — Taylor's  nar 
row-bluded*  forceps. 


FORCEPS. 


351 


vie  wall.  The  best  means  of  avoiding  these  two  difficulties  is  to  ex- 
ercise great  patience,  and  be  content  with  a  very  gradual  advan(;e  of 
the  head,  as,  by  omitting  anything  like  rude  force,  the  risks  arising 
from  misdirected  tractions  are  kept  within  the  limits  of  safety.  Many, 
indeed,  seek  to  prevent  the  anterior  pressure  of  the  forceps,  by  placing 
the  left  hand  upon  the  lock,  and  using  it  as  a  fulcrum  around  which 
rotation  of  the  instrument  is  effected.  As  the  right  hand  has  then 
to  be  employed  at  the  same  time  to  make  tractions  and  to  raise  the 
handles,  the  method  requires  both  strength  and  expertness  to  be  suc- 
cessful. 

In  all  high  operations  where  the  cervix  is  sufficiently  dilated,  I 
can  not  too  strongly  recommend  the  ingenious  forceps  of  M.  Tarnier, 
which,  by  its  construction  and  action,  obviates  to  a  great  extent  the 
foregoing  objections  to  the  more  familiar  models. 

M.  Tarnier's  forceps  possesses  two  original  features  :  1.  The  shanks, 
in  place  of  running  forward  continuous  with  the  pelvic  curve,  are  bent 
backward,  so  that  the  handles,  when  placed  horizontally,  lie  about 
three  and  a  half  inches  above  the  plane  of  the  posterior  curve  of  the 
blades.  This  Tarnier  curve  makes  it  possible  to  bring  the  blades  well 
forward  in  the  sides  of  the  pelvis  without  subjecting  the  soft  parts 
above,  or  the  perinaeum  below,  to  pressure.  A  transverse  scrcAV,  cross- 
ing the  handles  below  the  lock,  approximates  the  blades  to  the  sur- 
faces of  the  child's  head.  2.  Two  movable  traction-rods  are  attached 
to  the  lower  curvature  of  the  blades.  These  rods  are  curved  to  corre- 
spond to  the  lower  border  of  the  shanks,  to  which,  when  not  in  use, 
they  are  affixed  by  projecting  pegs.  When  the  instrument  is  adjusted, 
the  outer  ends  of  the  traction-rods  are  detached  and  inserted  into  a 
socket-joint  belonging  to  a  strong  steel  bar  with  a  downward  curve, 
and  furnished  with  a  transverse  handle  which  can  be  moved  in  any 
direction  by  means  of  a  universal  joint.  Tractions  are  made  by  means 
of  this  transverse  handle  alone.  As  the  head  descends,  the  handles 
proper  rise  upward  and  serve  as  an  index  to  show  the  direction  in  which 
the  force  should  be  exerted.  By  simply  raising  the  traction-rods  in  a 
line  with  the  curved  shanks,  the  blades  of  the  forceps  swing  always  in 
the  transverse  diameter,  and  the  head  follows  as  nearly  as  possible  the 
axis  of  the  pelvis.  To  one  accustomed  only  to  the  familiar  forceps, 
the  facility  with  which  delivery  can  be  accomplished  by  Tarnier's  in-  * 
strument  would  seem  hardly  credible. 

Mr.  Stohlmann  has  modified  for  me  the  original  forceps  of  Tarnier 
by  making  the  blades  much  lighter,  modeling  them  somewhat  after 
those  of  the  well-known  instrument  of  Wallace.  This  alteration  makes 
their  application,  especially  in  contracted  pelves,  or  through  an  imper- 
fectly dilated  os,  a  much  easier  matter.  In  place,  too,  of  the  very 
clumsy  socket-joint  into  which  the  traction-rods  are  inserted,  he  has 
substituted  the  key  arrangement  shown  in  Fig.  159,  by  means  of  which 


352 


OBSTETRIC  SURGERY. 


the  handle  can  be  adjusted  or  removed  in  a  few  seconds  of  time.  These 
improvements  do  away,  to  a  great  extent,  with  the  unhandiness  of  the 
older  model. 


Fig.  159. — Author's  modification  of  Tarnier's  forceps. 


As  the  solidity  of  the  shanks  prevents  the  blades  from  springing, 
the  amount  of  pressure  upon  the  head  requisite  to  keep  the  instrument 
from  slipping  has  been  found  in  practice  not  to  prove  an  element  of 
danger  to  the  child. 

When  the  head  has  been  brought  to  the  floor  of  the  pelvis,  unless 
the  occiput  has  previously  turned  to  the  front,  it  is  a  good  plan  to  re- 
move the  forceps  and  wait  a  little  while  to  allow  spontaneous  rotation 
to  take  place.  Indeed,  it  is  a  question  whether  axis-traction  forceps 
should  be  employed  at  all  at  the  inferior  strait.  Unless  accurately 
applied  to  the  lateral  surfaces  of  the  child's  head,  the  backward  curve, 
so  useful  at  the  brim,  is  apt  to  cut  deeply  into  the  i:)osterior  vaginal 
wall  as  soon  as  the  converging  soft  parts  embrace  tightly  the  advancing 
head. 

Forceps  in  Occipito-posterior  Positions.— So  long  as  the  occiput 
looks  to  the  rear,  it  is  the  rule  in  midwifery  practice  to  refrain  from 
the  use  of  forceps,  which,  of  necessity,  prevents  forward  rotation  from 
taking  place.  An  exception  to  this  rule,  hoAvever,  arises  in  cases  of 
a  near  danger  to  either  mother  or  child  demanding  speedy  delivery. 
As  attempts  to  rotate  the  occiput  around  to  the  symphysis  by  instru- 
mental means  are  rarely  successful,  it  is  advisable  under  such  circum- 
stances to  apply  the  forceps  directly  to  the  sides  of  the  child's  head, 
and  to  imitate  during  delivery  the  mechanism  of  labor  in  occipito-pos- 
terior positions.  If  the  sagittal  suture  occupies  an  oblique  diameter, 
the  forceps  should  be  applied  in  the  opposite  oblique  diameter.  As  the 
head  descends,  the  occiput  should  be  turned  into  the  hollow  of  the 
sacrum.  At  first,  tractions  should  be  made  directly  downward  until 
the  forehead  has  passed  under  the  pubic  arch,  and  the  anterior  fonta- 
nelle  makes  its  appearance  at  the  vulva  ;  then,  by  raising  the  handles, 
the  small  fontanelle  should  be  brought  forward  to  the  commissure,  and, 
finally,  as  the  vertex  emerges  from  the  vulva,  the  handles  should  be 


FORCEPS. 


353 


slowly  depressed  to  aid  the  moyement  of  extension  by  which  the 
delivery  of  the  face  and  chin  beneath  the  pubic  arch  is  accom- 
plished. 

Forceps  in  Face  Presentations. — When  the  face  is  deep  in  the  pelvis 
and  the  chin  has  rotated  to  the  front,  forceps  applications  are  easy  and 
do  not  differ  materially  from  those  in  vertex  presentation,  except  that 
care  should  be  taken  to  direct  the  blades  far  enough  backward  to  se- 
curely seize  the  occipital  extremity  of  the  child's  head.  Tractions 
should  be  made  in  an  horizontal  direction  until  the  chin  has  been 
brought  well  under  the  symphysis  pubis,  when  the  handles  should  be 
raised  to  lift  the  cranial  vault  over  the  perina^um.  In  oblique  mento- 
anterior positions,  Spiegelberg  advises  introducing  first  the  blade  cor- 
responding to  the  chin  (posterior  blade),  as,  in  adjusting  the  second 
blade  and  locking  the  forceps,  spontaneous  rotation  usually  takes 
place. 

In  deep  transverse  positions,  forceps  operations  should  be  deferred 
as  long  as  possible,  as  tardy  rotation  of  the  chin  to  the  front  is  a  physi- 
ological peculiarity  in  face  presentations.  The  forceps  should  be  ap- 
plied in  an  oblique  diameter,  with  the  concavity  of  the  blades  directed 
to  the  side  of  the  chin.  Chin  right,  introduce  the  right  blade  pos- 
teriorly, and  bring  the  left  blade  forward  to  the  left  tuberculum  ilio- 
pubicum.  An  effort  should  then  be  made  to  rotate  the  chin  to  the 
front.  If  the  attempt  prove  successful,  the  forceps  should  be  un- 
locked, and  the  blades  readjusted  to  the  lateral  surfaces  of  the  head. 
Tractions  when  the  face  is  transverse  should  not  be  attempted.  The 
wide  separation  of  the  blades  makes  it  necessary  to  compress  the  han- 
dles firmly  to  prevent  slipping.  AVhen  this  is  done,  pressure  upon  the 
neck  and  thorax  is  unavoidable,  so  that  extraction  without  sacrificing 
the  life  of  the  child  is  hardly  possible. 

In  high  transverse  positions,  forceps  should  not  be  used,  as  rota- 
tion is  not  then  permissible,  and  the  blades,  api:>lied  to  the  neck  and 
thorax  on  the  one  side  and  upon  the  cranium  on  the  other,  can  not, 
for  the  reasons  just  given,  be  safely  employed  in  extraction.  The 
choice  in  such  cases,  when  speedy  delivery  is  called  for,  lies  between, 
version  and  craniotomy. 

In  mento-posterior  positions,  the  rotation  of  the  chin  to  the  front 
by  repeated  applications  of  the  forceps  is  inadmissible.  In  practice, 
such  efforts  do  not  succeed,  while  they  are  calculated  to  inflict  injury 
upon  both  the  mother  and  the  child.  Usually,  if  delivery  becomes 
necessary  because  of  danger  to  the  mother,  craniotomy  should  be  re- 
sorted to.  Smellie,  Hicks,*  and  Braun,  of  Vienna,  have,  however, 
each  reported  a  case  of  forceps  delivery  by  drawing  the  chin  down  over 

*  Hicks,  *'  On  Two  Cases  of  Face  Presentations  in  the  Mento-posterior  Position," 

"  Trans,  of  the  Obstet.  Soc,  of  London,"  vol,  vii,  p.  56.  Ilicks  likewise  reports  the  casesj 
of  Smellie  and  Eraun. 

23 


354  OBSTETRIC  SURGERY. 

the  sacrum  and  perinaeum,  when  the  occiput  and  calvarium  glided 
underneath  the  pubes.    In  two  cases,  I.  E.  Taylor  *  extracted  the  chil- 


FiG.  160. — Taylor's  method  in  mento-posterior  positions  of  the  face. 


dren  with  straight  forceps  after  bilateral  incision  of  the  perinaeum. 
Unfortunately,  both  children  were  dead  before  the  operation  was  un- 
dertaken. 


CHAPTER  XX. 

EXTRACTION  IN  FOOT  AND  BREECH  PRESENTATIONS. 

Extraction  in  pelvic  presentations. — Attitude  of  the  physician. — Prognosis. — Position. — 
Extraction  of  trunk. — Extraction  by  the  feet ;  by  the  breech. — Management  of  the 
cord. — Liberation  of  the  arms. — Exceptional  cases. — Extraction  of  the  head. — Smel- 
lie's  method. — Veit's  method. — Head  at  brim. — Prague  method. — Forceps  to  the  after- 
coming  head. 

We  have  already  seen,  in  studying  the  management  of  breech  pres- 
entations, that  the  attitude  of  the  physician  during  delivery,  so  long 
as  no  immediate  danger  threatens  either  the  mother  or  the  child, 
should  be  one  of  watchful  observation.  As  a  rule,  the  results  to  the 
child  are  unquestionably  more  favorable  when  Nature  does  her  work 
unaided.     Should,  however,  there  be  any  faltering  in  the  natural 

*  Taylor,  "  On  the  Spontaneous  and  Artificial  Delivery  of  the  Child  in  Face  Presenta- 
tions," "N.  Y.  Med.  Jour.,"  Nov.,  1869. 


EXTRACTION  IN  FOOT  AND  BREECH  PRESENTATIONS. 


355 


forces,  the  physician  should  be  in  readiness  to  avert  by  prompt  inter- 
ference the  perils  which,  in  pelvic  presentations,  are  associated  with 
delay.  When  an  artificial  breech-presentation  has  been  produced  by 
internal  version,  immediate  extraction  is  usually  advisable,  as  the  act 
of  version,  when  the  entire  hand  has  to  be  introduced  into  the  uterus, 
is  apt  to  compromise  the  safety  of  the  child. 

Strong  uterine  contractions,  a  roomy  pelvis,  a  dilated  cervix,  and 
a  relaxed  state  of  the  vaginal  outlet  are  conditions  highly  favorable  to 
the  success  of  the  operation.  Under  such  circumstances,  artificial 
delivery  can  be  performed  with  celerity  and  ease.  But  these  condi- 
tions, however  desirable,  are  not  absolutely  indispensable.  Thus,  ex- 
traction is  rarely  indicated  if  the  pains  are  good  ;  it  is  often  necessary 
to  deliver  before  the  cervix  has  reached  the  desirable  degree  of  dilata- 
tion ;  and  it  is  possible  to  drag  the  head  of  the  child  through  a  moder- 
ately contracted  pelvis  without  inflicting  upon  it  any  permanent  in- 
jury. There  is  always  danger,  however,  in  the  last  two  cases,  of 
not  being  able  to  extract  the  child  rapidly  enough  to  save  it  from 
asphyxia. 

The  prognosis  for  the  mother  is  generally  favorable.  Still,  lacera- 
tions are  apt  to  follow  the  forcible  delivery  of  the  head  through  the 
undilated  cervix. 

Extraction  is  commonly  performed  with  the  patient  on  her  back. 
In  easy  cases  she  may  occupy  the  usual  position  in  bed,  while  the  phy- 
sician places  himself  at  her  side.  If  difficulty  is  anticipated,  the  pa- 
tient should  be  placed  crosswise,  with  hips  raised  by  a  hard  cushion, 
and  brought  over  the  edge  of  the  bed  ;  or,  better  still,  may  be  placed 
upon  a  table,  as  the  operator  is  then  enabled  to  draw  downward  in  the 
direction  of  the  superior  strait  without  kneeling  before  her.  It  is  de- 
sirable to  have  two  assistants  to  hold  the  patient's  knees.  To  one  of 
these  should  likewise  be  assigned  the  duty  of  making  firm  pressure, 
during  extraction,  upon  the  fundus  of  the  uterus.  If  anaesthesia  is 
thought  necessary,  a  third  assistant  will  be  required.  The  question 
of  anaesthesia  is  not  always  easy  to  decide.  Useful  in  unruly  patients, 
and  where  the  entire  hand  must  be  passed  into  the  vagina,  its  occa- 
sional suspensive  action  upon  the  uterine  pains  and  the  loss  of  the 
cooperation  which  intelligent  patients  are  capable  of  affording  are 
alloys  to  its  beneficent  action  in  stilling  pain.  My  preference  is  to 
anaesthetize  lightly  at  first,  and  then  be  guided  by  events  as  to  whether 
the  insensibility  shall  be  subsequently  made  complete  or  the  patient 
be  allowed  to  return  to  partial  consciousness. 

As  in  all  obstetrical  operations,  care  should  be  taken  to  insure  the 
emptying  of  the  bladder  and  rectum,  and  the  operator  should  have  in 
readiness,  in  case  of  need,  forceps,  a  soft  fillet,  warm  napkins,  hot  and 
cold  water,  and  a  small  catheter,  for  use  should  the  child  be  bom  in 
a  state  of  partial  asphyxia. 


356 


OBSTETEIC  SURGERY. 


The  operation  is  divisible  into  three  acts  :  1.  Extraction  of  the 
trunk,  as  far  as  the  shoulders ;  2.  Extraction  of  the  arms ;  3.  Ex- 
traction of  the  head. 

EiKST  Act  :  Extraction  of  the  Teunk  to  the  Shoulders. 

The  extraction  of  the  trunk  should  take  place  slowly,  with  pauses 
between  the  tractions,  in  imitation  of  the  uterine  expellent  forces. 
Tractions  are  best  made  during  the  pains  only,  when  the  latter  do  not 
recur  at  too  long  intervals.  It  is  desirable  that  the  uterus  be  closely 
retracted  upon  the  child  during  the  entire  period  of  its  expulsion. 
"Where  this  does  not  occur,  the  arms  are  liable  to  be  brushed  upward 
to  the  sides  of  the  child's  head,  the  chin  to  become  extended,  and  the 
mechanism  of  the  head-delivery  to  be  disturbed.  Haemorrhage,  too, 
is  more  likely  to  follow  hasty  delivery  than  where  the  uterus  has  had 
time  to  pass  slowly  into  a  state  of  complete  retraction.  When,  there- 
fore, it  is  necessary  to  extract  during  the  intervals  between  the  pains, 
firm  pressure  should  be  made  upon  the  uterus  through  the  abdominal 
walls,  so  as  to  maintain  them  in  close  contact  with  the  foetus.  Steady 
tractions  are  preferable  to  pendulum  movements.  Tractions  should 
be  made  downward  and  backward, .  in  the  direction  of  the  superior 
strait,  until  the  breech  meets  with  the  resistance  of  the  floor  of  the 
pelvis. 

These  general  rules  are  applicable  to  every  case  of  extraction. 
Special  differences  of  procedure  result  from  the  presentation  of  one  or 
both  feet,  and  of  the  entire  breech. 

Extraction  by  the  Feet. — If  a  single  extremity  presents,  the  foot 
should  be  seized  between  the  middle  and  index  finger,  with  the  thumo 
upon  the  sole.  It  is  not  necessary  to  go  in  search  of  the  second  foot, 
unless  it  crosses  the  first,  or  is  reflected  upward  over  the  child's  back. 
When  the  leg  is  drawn  outside  of  the  vulva,  it  should  be  wrapped  in  a 
warm  napkin,  and  grasped  by  the  entire  hand.  Always,  in  seizing  a 
limb,  the  thumb  should  be  directed  upward  and  ap2:)lied  to  the  dorsal 
surface.  The  napkin  serves  partly  to  prevent  the  hand  from  slipping, 
partly  to  protect  the  surface  from  air,  which  at  times  is  capable  of 
exciting  reflex  respiratory  movements.  Tractions  should  be  made 
downward,  to  avoid  friction  at  the  symphysis  pubis.  Until  the  pelvis 
is  delivered,  the  child  should  be  seized  as  near  the  maternal  parts  as 
possible.  The  hand,  therefore,  should  be  sliifted  upward  as  the  limb 
is  drawn  out  of  the  vulva.  Whichever  extremity  is  seized  rotates  for- 
ward under  the  symphysis  pubis  during  extraction.  So  soon  as  the 
breech  reaches  the  pelvic  floor,  traction  should  be  made  more  in  an 
upward  direction,  to  facilitate  the  passage  of  the  buttocks  over  the 
peringeum.  After  the  breech  has  cleared  the  vulva,  the  index-finger 
of  the  free  hand  should  be  carefully  inserted  into  the  fold  of  the  ])os- 
terior  thigh,  while  tlie  thumbs  of  both  hands  are  placed  upon  the 


EXTRACTION  IN  FOOT  AND  BREECH  PRESENTATIONS. 


357 


sacrum.  During  the  subsequent  extraction  of  the  trunk,  the  lower  leg 
falls  from  the  vagina  without  special  assistance. 


Fig.  161. — Method  of  seizing  both  feet. 


If  both  extremities  present,  they  should  be  seized  so  that  the  mid- 
dle finger  is  placed  between  the  feet,  while  the  index  and  ring  fingers 
encircle  the  external  malleoli.  After  they  have  passed  sufficiently  far 
outside  the  vulva,  the  left  leg  should  be  seized  with  the  left  hand,  and 
the  right  foot  with  the  right  hand.  .  During  extraction  the  normal 
rotation  of  the  child  may  be  aided  by  dragging  with  somewhat  greater 
force  upon  the  limb,  which  should  be  turned  to  the  front. 

Extraction  by  the  Breech. — When  the  breech  alone  presents,  it 
may  be  thought  best  to  secure  a  foot,  previous  to  the  descent  of  the 
child  into  the  pelvis,  as  a  prophylactic  measure,  in  case  extraction 
should  subsequently  be  found  necessary.  In  this  event,  with  both 
feet  reflected  upward,  the  hand  should  be  passed  over  the  anterior 
surface  of  the  child  to  the  knee  of  the  front  extremity  ;  the  thumb 
should  then  be  placed  in  the  popliteal  space,  while  four  fingers  grasp 
the  leg,  flex  it  upon  the  thigh,  and  draw  it  down  into  the  vagina. 


358 


OBSTETRIC  SURGERY. 


This  operation  is  facilitated  by  placing  the  patient  upon  the  side  to 
which  the  child's  feet  are  turned. 

After,  however,  the  breech  has  once  fairly  engaged  in  the  pelvis, 
the  execution  of  this  manoeuvre  is  no  longer  easy.  The  attempt  to 
bring  down  an  extremity  by  the  side  of  the  breech  in  the  pelvis  is 
liable  to  cause  fracture  of  the  thigh.  Then,  too,  the  introduction  of 
the  hand  is  not  always  possible  without  the  exercise  of  an  unjustifi- 
able degree  of  force.  In  such  cases  an  attempt  should  be  made  to  push 
the  foetus  downward  during  the  pains,  by  graduated  pressure  upon 
the  fundus  of  the  uterus.  Should  this  measure  prove  insufficient, 
manual  extraction  should  be  attempted.  To  this  end  the  index-finger 
of  one  hand  should  be  inserted  into  the  fold  of  the  anterior  thigh,  and 
traction  made  directly  downward.  By  seizing  the  wrist  of  the  hand 
which  is  hooked  into  the  thigh  with  the  disengaged  hand,  an  increase 
of  traction  power  can  be  exerted.  Where  the  breech  is  low  enough 
down,  both  index-fingers  may  be  employed — the  one  in  the  anterior 


Fig.  1G2.— Method  of  seizing  the  breech. 


and  the  other  in  the  posterior  groin.  Extraction  is  then  effected  by 
alternately  raising  and  depressing  the  pelvic  extremity. 


EXTRACTION  IN  FOOT  AND  BREECH  PRESENTATIONS. 


359 


Sometimes  the  resistance  of  the  soft  parts  is  such  as  to  set  all  our 
best  efforts  in  the  way  of  manual  extraction  at  defiance.  Then  a  beg- 
garly array  of  alternatives  present  themselves  to  us.  These  are  :  1. 
The  blunt  hook,  which  should  be  passed  upward  in  the  direction  of 
the  child's  forward  knee,  and  then  turned  and  withdrawn  so  as  to 
bring  the  curved  extremity  into  the  groin.  The  blunt  hook  furnishes 
a  good  hold,  and  may  be  used  to  materially  further  delivery.  Some 
contusion  is,  however,  inevitable  from  its  employment.  Great  care 
must  be  exercised  to  see  that  the  instrument  is  well  placed.  Should 
it  slip  forward  upon  the  thigh  during  tractions,  the  thigh-bone  is  liable 
to  be  fractured.  The  risks  to  the  child,  from  even  its  careful  employ- 
ment, are  so  great  that  the  blunt  hook  is  rarely  used  excepting  where 
the  child  is  believed  to  have  perished.  2.  The  fillet,  formed  of  a  silk 
handkerchief,  a  skein  of  worsted,  a  wide  strip  of  linen,  or  of  any  soft 
material,  which,  when  passed  around  the  thigh,  may  be  used  to  aid  ex- 
traction. In  placing  the  fillet,  one  end  may  be  knotted,  or  rolled  into  a 
ball,  and  conveyed  by  the  index  and  middle  fingers  around  the  anterior 
thigh,  or  an  English  elastic  catheter,  having  been  first  guided  around 
the  groin,  may  be  employed  to  draw  the  fillet  into  position.  Before 
extracting,  pains  should  be  taken  to  see  that  the  fillet  is  smoothly  ad- 
justed, and  fits  well  into  the  flexure  of  the  thigh.  To  its  use  it  has 
been  objected  that  the  fillet  is  apt  to  become  twisted,  and,  when  moist- 
ened with  the  vaginal  secretions,  forms  an  uneven  band  capable  of 
cutting  deeply  into  the  tissues.  While,  however,  these  drawbacks 
should  admonish  us  to  caution,  the  testimony  is  abundant  as  to  the 
serviceability  and  relative  safety  of  the  measure.  3.  The  obstetric  for- 
ceps may  be  applied  to  the  breech,  in  cases  where  the  latter  rests  upon 
the  floor  of  the  pelvis,  and  where  the  pains  are  insufficient  to  overcome 
the  resistance  of  the  perinasum.  The  employment  of  forceps  in  breech 
cases  has  been  generally  decried  from  theoretical  considerations.  The 
experiences  of  Hiiter  and  Haake  *  have,  however,  been  favorable.  The 
latter  limited  the  use  of  forceps  to  cases  in  which  the  breech  was 
already  in  the  pelvic  outlet,  and  after  complete  rotation  had  taken 
place.  The  forceps  was  applied  with  one  blade  over  the  posterior 
thigh,  and  the  other  over  the  sacrum,  with  the  extremity  of  the  latter 
blade  just  above  the  crest  of  the  ilium. 

Management  of  the  Cord. — So  soon  as  the  cord  has  passed  beyond  the 
vulva,  dragging  upon  the  navel  should  be  avoided  by  gently  pulling 
the  cord  downward  into  one  of  the  recesses  to  the  sides  of  the  prom- 
ontory until  some  resistance  is  experienced.  Sometimes  the  cord  is 
found  passing  between  the  child's  legs  and  up  over  its  back  to  the 
placenta.  Then  traction  should  be  exerted  upon  the  placental  extrem- 
ity, and  an  attempt  made  to  slip  the  loop  over  the  posterior  thigh.  In 

*  HuTER,  "  Compendium  der  Operationen,"  Leipzi,<r,  p.  203  ;  Haake,  *'  Ueber  den 
Gebrauch  der  Kopfzangen  zur  Extraction,"  "  Arch.  f.  Gynaek.,"  Bd.  xi,  p.  558. 


360 


OBSTETRIC  SURGERY. 


the  rare  cases  of  failure  to  obtain  its  release,  and  where  the  cord  is 
wound  around  the  child's  body,  two  ligatures  should  be  applied,  and 
the  cord  be  divided  between  them,  whereupon  every  effort  should  be 
put  forth  to  complete  the  delivery  as  speedily  as  possible. 

Second  Act  :  Libekatiok  of  the  Akms. 

When  the  Arms  are  flexed  upon  the  Thorax. — After  providing  for 
the  safety  of  the  cord,  the  pelvis  of  the  child  should  be  seized  in  the 
two  hands  with  the  thumbs  upon  the  sacrum.  Traction  should  be 
employed  in  a  downward  direction  until  the  shoulder-blades  make 
their  appearance.  Then  no  time  should  be  lost  in  liberating  the  arms. 
If  the  latter  are  folded  upon  the  chest,  delivery  is  an  easy  matter.  The 
palmar  surface  of  the  corresponding  hand  is  passed  over  the  belly  of  the 
child  to  the  posterior  arm  (back  to  the  right,  right  hand,  and  vice  ver- 
sa), while  the  extremities,  wrapped  in  a  warm  cloth,  are  drawn  in  the 
opposite  direction.  The  forearm  should  be  seized  as  near  the  wrist  as 
possible,  and  be  brought  down  over  the  abdomen  to  the  side  of  the  child. 

When  the  Arms  are  extended. — Unless,  however,  great  care  has 
been  exerted  during  extraction  to  keep  the  uterus  by  external  press- 
ure closely  in  contact  with  the  foetus,  the  friction  of  the  parturient 
canal  is  apt  to  brush  one  or  both  arms  upward  to  the  sides  of  the 
child's  head.  In  such  cases  the  difficulties  involved  in  liberating  the 
arms  are  often  very  great.  Here,  too,  owing  to  the  increased  amount 
of  space  afforded  by  the  curvature  of  the  sacrum,  an  attempt  should 
first  be  made  to  release  the  posterior  arm. 

Release  of  the  Posterior  Arm. — This  is  best  accomplished  by  draw- 
ing the  lower  extremities  strongly  upward  and  to  the  side,  thereby  caus- 
ing the  posterior  shoulder  to  sink  deeper  in  the  pelvis  and  to  furnish 
more  room  for  the  introduction  of  the  hand  ;  then  two  fingers  should 
be  passed  along  the  side  of  the  child  to  the  elbow-joint,  which  should 
be  pushed  across  the  face,  and  be  brought  down  over  the  thorax. 

In  case  the  foregoing  manoeuvre  can  not  be  rapidly  executed,  the 
operating  hand  may  be  removed,  and  the  extremities  of  the  child  may 
be  drawn  in  the  opposite  direction,  while  the  hand  which  at  first  had 
seized  the  feet  or  breech  should  pass  upward  over  the  abdominal  sur- 
face to  the  posterior  elbow,  and  bend  it,  with  two  fingers  in  the  joint, 
toward  the  anterior  pelvic  wall. 

Whether  the  hand  be  passed  behind  or  in  front  of  the  child,  it 
should  be  introduced  slowly  and  without  force  during  the  intermission 
between  the  pains.  Pressure  should  always  be  made  at  the  joint,  and 
never  upon  the  humerus.  A  forgetfulncss  of  the  latter  rule  is  apt  to 
produce  fracture. 

Release  of  the  Anterior  Arm. — As  there  is  rarely  space  enough 
between  the  symphysis  and  the  shoulder  to  allow  the  fingers  to  reach 
the  elbow,  it  is  customary  after  release  of  the  posterior  arm  to  rotate 


EXTRACTION  IN  FOOT  AND  BREECH  PRESENTATIONS. 


361 


the  trunk  so  as  to  bring  the  anterior  arm  backward  into  the  cavity  of 
the  sacrum.  This  is  accomplished  eitlier  by  clasping  the  thorax  in 
both  hands  and  rotating  while  pushing  the  thorax  inward,  or  better 
still  by  seizing  the  liberated  arm,  and  drawing  it  upward  under  the 
symphysis  pubis.  Indeed,  the  latter  method  has  so  far  never  failed  me 
in  readily  securing  the  desired  rotation.  (If  the  back  is  turned  to  the 
left,  the  arm  should  be  drawn  upward  along  the  left  labium  majus, 
and  vice  versa.) 

Exceptional  Cases. — The  shoulders,  in  place  of  rotating  into  the 
conjugate  diameter,  may  enter  transversely  into  the  pelvis.  If  the 
back  then  be  turned  toward  the  symphysis,  the  hand  should  be  passed 
over  the  abdominal  surface  in  search  of  the  arms.  The  space  oppo- 
site the  sacrum  renders  this  movement  one  of  easy  execution.  When 
the  back  is  turned  to  the  rear,  so  long  as  the  arms  are  flexed,  the  hand 
should  search  for  them  under  the  symphysis  pubis.  If,  however,  they 
are  extended  upon  the  sides  of  the  child's  head,  it  is  rarely  possible  to 
push  the  arms  forward  between  the  face  and  the  symphysis  pubis. 
An  effort  should  be  made,  therefore,  to  bring  one  arm  to  the  rear  by 
rotating  the  thorax  with  the  hands.  Michaelis  succeeded  twice  in 
similar  cases  without  rotating  the  trunk,-  by  pushing  the  elbow  back- 
ward until  it  could  be  brought  below  the  side-wall  of  the  pelvis,  and 
then  drawing  the  forearm  over  the  thorax.*  I  have  repeatedly  tested 
this  movement  in  passing  the  cadaver  of  an  infant  through  a  bony 
pelvis,  and  find  that  it  can  be  accomplished  without  producing  fract- 
ure or  dislocation.  Of  course,  during  the  life  of  the  child  the  result 
may  be  different. 

Sometimes,  in  rotating  the  shoulders,  the  anterior  arm  becomes 
displaced  backward,  so  that  the  forearm  is  thrown  across  the  neck  of 
the  child.  When  this  accident  is  of  recent  occurrence,  the  release  of 
the  arm  may  be  accomplished  by  pressing  the  thorax  of  the  child  back- 
ward into  the  genital  passage,  and  rotating  the  body  in  the  reverse 
direction  from  that  which  produced  the  difficulty.  If,  however,  trac- 
tions have  been  made  upon  the  child  until  the  head  has  entered  the 
pelvis,  the  arm  may  become  so  compressed  between  the  neck  and  the 
symphysis  pubis  as  to  render  its  liberation  a  very  difficult  if  not  im- 
possible task.  Then  every  resource  should  be  quickly  tested  to  turn  the 
shoulder  of  the  displaced  arm  to  the  rear,  either  by  raising  the  released 
arm,  or  by  rotating  the  thorax,  or  by  drawing  upon  the  elbow.  In  case 
of  failure  to  obtain  a  speedy  result,  extraction  may  be  attempted  with- 
out releasing  the  arm.  To  be  sure,  fracture  of  the  humerus  is  thereby 
rendered  highly  probable,  but,  if  the  bystanders  are  forewarned  that 
the  risk  is  incurred  in  the  interest  of  the  child,  they  are  generally 
ready,  where  the  life  of  the  latter  is  preserved,  to  condone  the  injury. 

In  setting  a  fractured  arm,  soft  pads  should  be  bandaged  upon  the 
*  Michaelis,  "  Abhandlungcn,"  Kiel,  1833,  p.  230. 

( 


362 


OBSTETRIC  SURGERY. 


anterior  and  posterior  surface  to  hold  the  extremities  in  position.  The 
posterior  pad  should  run  the  entire  length  of  the  arm ;  the  anterior 
pad  need  not  extend  below  the  elbow.  The  arm  should  then  be  band- 
aged to  the  thorax.  In  two  or  three  weeks  consolidation  takes  place.* 
In  performing  artificial  rotation,  it  is  well  to  bear  the  warning  of 
Dr.  Barnes  in  mind,  viz.,  That  the  atlas  forms  with  the  axis  a  rota- 
tory joint,  so  constructed  that,  if  the  movement  of  rotation  of  the  head 
be  carried  beyond  a  quarter  of  a  circle,  the  articulating  surfaces  part 
immediately,  and  the  spinal  cord  is  compressed  or  torn."  f  Pains 
should  accordingly  be  taken  to  note,  when  a  half-turn  is  given  to  the 
body,  whether  the  head  follows  the  movements  of  the  trunk. 

Third  Act  :  Extractioi^  of  the  Head. 

In  the  extraction  of  the  head  we  have  to  distinguish — 1.  Cases  in 
which  the  head  has  entered  the  pelvis,  and  has  only  to  overcome  the 
resistance  of  the  perinseum  ;  2.  Cases  where  the  head  is  retained  at 
the  brim  by  pelvic  contraction,  stricture  of  the  os  uteri,  extension  of 
the  chin,  or  insufficient  exjDulsive  action  exerted  by  the  uterus  and 
the  abdominal  muscles. 

1.  Extraction  of  the  head  after  it  has  entered  the  pelvis. 

Smellie's  Method. — In  the  so-called  Smellie's  method  the  trunk  of 
the  child  is  wrapped  in  a  warm  napkin  and  placed  astride  the  opera- 
tor's arm  ;  the  hand  is  then  passed  into  the  vagina,  and  the  index  and 
middle  fingers  are  placed  upon  the  fossae  caninse  to  the  sides  of  the 
child's  nose.  By  this  means  flexion  of  the  head  is  induced.  At  the 
same  time,  upward  pressure  is  made  with  the  fingers  of  the  other  hand 
upon  the  occiput.  Then  by  raising  the  trunk  the  face  is  rolled  out 
over  the  perinaeum.  This  method  possesses  the  advantage  of  avoiding 
the  risks  of  injuring  the  child  which  are  incident  to  the  other  proced- 
ures. It  requires  for  its  successful  performance  the  comj^letion  of 
rotation,  a  small  head,  and  a  lax  perinaeum. 

Combined  Traction  upon  the  Chin  and  Shoulders. — In  case  the  fore- 
going plan  is  not  followed  by  immediate  success,  the  two  fingers  upon 
the  fossae  caninae  should  be  introduced  into  the  mouth,  and,  by  press- 
ure upon  the  alveolar  processes  of  the  lower  jaw,  flexion  should  be 
accomplished.  With  the  fingers  of  the  other  hand  forked  upon  the 
shoulders  traction  should  be  made,  and  as  the  head  descends  the 
body  should  be  raised  by  the  joint  movement  of  the  two  arms,  where- 
by the  face  sweeps  over  the  perinaeum.  By  the  combined  method 
there  is  obtained  the  greatest  amount  of  traction  force  in  combination 
with  the  least  degree  of  violence  to  the  child.  As  the  power  is  exerted 
chiefly  upon  the  shoulders,  the  fingers  in  the  mouth  are  not  likely  to 
fracture  the  jaw,  but,  by  keeping  the  chin  flexed  and  drawing  gently 

*  Spiegelderg,  "  Lchrbucli,"  etc.,  p.  809. 

f  Barnes,  "  Obst.  Operations,"  Am.  cd.,  p.  210. 


EXTRACTION  IN  FOOT  AND  BREECH  PRESENTATIONS.  363 

upon  it,  the  danger  of  twisting  the  neck,  in  cases  where  the  rotation 
of  the  face  into  the  hollow  of  the  sacrum  is  incomplete,  is  avoided.* 


Fig.  1G3. — Combined  traction  upon  mouth  and  shoulders.  (Chailly-IIonore.) 

When  the  occiput  is  turned  into  the  hollow  of  the  sacrum,  and  the 
forehead  is  pressed  against  the  symphysis,  the  process  just  described 
should  be  reversed.  As  the  fingers  are  forked  over  the  shoulders,  the 
back  of  the  child  should  rest  upon  the  arm.  With  one  or  two  fin- 
gers of  the  other  hand  the  chin  should  be  flexed.  1'ractions  should 
be  made  downward,  so  that  while  the  neck  rests  upon  the  perinaeum 
the  forehead  rotates  under  the  sympliysis  pubis. 

Ordinarily,  when  the  head  enters  the  pelvis  in  a  transverse  direc- 
tion, the  occiput  rotates  to  the  symphysis  pubis  during  extraction. 
Should  the  head,  however,  remain  with  its  long  diameter  in  the  trans- 
verse diameter  of  the  pelvis,  a  hand  introduced  into  the  vagina,  with 
the  back  to  the  sacrum  and  the  fingers  over  the  child's  face,  may 
sometimes  be  successfully  employed  to  rotate  the  latter  into  the  sacral 
concavity. 

2.  Extraction  with  the  Head  at  the  Brim.— Schroeder,  and  a  con- 
siderable portion  of  the  modern  German  school,  employ  combined  trac- 
tion upon  the  shoulder  and  chin  for  all  emergencies  alike,  whether  the 
head  be  high,  or  after  its  entrance  into  the  pelvis.  As,  however,  the 
life  of  the  child  depends  upon  the  speedy  extraction  of  the  head,  it  is 
well  to  become  familiar  with  the  various  procedures,  as,  by  passing 

*  The  combined  traction  upon  the  chin  and  shoulders  is  in  Germany  known  as  the 
Smellie-Veit  modified  method,  the  latter  having  warmly  advocated  the  measure  in  1863. 
Chailly,  however,  long  before  spoke  of  its  adoption  in  France,  and  attributed  its  introduc- 
tion to  Mme.  La  Chapellc. 


364 


OBSTETRIC  SURGERY. 


rapidly  from  one  to  another,  a  successful  result  is  often  obtained,  when 
failure  might  have  followed  ineffectual  efforts  in  a  single  direction. 

The  Prague  Method  owes  its  modern  name  to  the  advocacy  of 
Kiwisch,  Scanzoni,  and  Lange,  all  representatives  of  the  Prague 

school.  It  was,  however,  nearly  a  cen- 
tury earlier  described  by  Pugh.  It 
consists  in  seizing  the  feet  with  one 
hand,  and  directing  the  body  of  the 
child  nearly  vertically  downward .  The 
fingers  of  the  other  hand  are  hooked 
over  the  shoulders  of  the  child,  so  that 
the  tips  rest  upon  the  supra-clavicular 
region.  Traction  is  exerted  by  both 
hands  simultaneously.  In  the  absence 
of  pains,  external  pressure  upon  the 
head  should  be  made  by  an  assistant 
through  the  abdominal  walls.  Care 
should  be  taken  to  avoid  twisting  the 
neck,  and  to  preserve  the  normal  rela- 
tions between  the  head  and  the  shoul- 
ders. After  the  head  has  passed  the 
brim,  and  fairly  entered  the  pelvis,  the 
hand  upon  the  neck  should  be  em- 
ployed as  a  fulcrum,  while  the  extrem- 
ities are  raised  rapidly  toward  the  ab- 
domen of  the  mother ;  the  friction 
from  the  inner  surface  of  the  symphysis 
pushes  the  occij)ut  upward,  and  forces 
the  face  to  descend  into  the  hollow  of 
the  sacrum  and  to  sweep  over  the  pe- 
rinaeum. 

When  the  chin  is  directed  to  the 
front,  and  at  the  same  time  is  arrested 
at  the  symphysis  pubis,  if  the  occiput 
occupies  the  hollow  of  the  sacrum,  the 
body  of  the  child  should,  during  the 
tractions,  be  directed  toward  the  abdomen  of  the  mother,  so  as  to 
cause  the  occiput  to  rotate  over  the  perina3um. 

Forceps  to  the  After-coming  Head.— The  forceps  to  the  after-coming 
head  has  been  condemned  by  some  and  warmly  approved  by  others. 
As,  however,  with  its  aid  I  have,  in  a  number  of  instances,  extracted 
children  alive  in  cases  where  the  foregoing  methods  have  failed  me, 
it  is  now  my  custom  to  have  the  blades  duly  warmed  and  ready  to  hand 
before  attempting  manual  extraction.  The  instrument  is  occasionally 
of  use  in  overcoming  the  resistance  of  a  rigid  peringeum  in  strongly- 


FlG. 


164, — The  method  of  extracting; 
the  trunk. 


EXTRACTION  IN  FOOT  AND  BREECH  PRESENTATIONS. 


365. 


built  primiparae,  but  is  chiefly  indicated  when  both  occiput  and  chin 
are  arrested  at  the  superior  strait.    With  the  chin  anterior,  the  forceps 


Fig.  165. — The  Prague  method  of  extracting  head. 


should  be  applied  under  the  back  of  the  child,  and  the  handles  raised 
so  as  to  bring  the  occiput  into  the  hollow  of  the  sacrum.  With  the 
chin  to  the  rear,  the  forceps  should  be  applied  under  the  abdomen. 


Fig.  166.— Chin  arrested  at  symphysis.  (Chailly-Honor^.) 


366 


OBSTETRIC  SURGERY. 


and  be  used  to  draw  the  face  into  the  sacrum.  Where  the  arrest  of  the 
head  is  due  to  stricture  of  the  os  externum  or  internum,  the  forceps 
will  sometimes  bring  the  head  rapidly  through  the  cervix,  when  trac- 
tion upon  the  feet  only  serves  to  drag  the  uterus  to  the  vulva.  In 
stricture  of  the  cervix,  however,  great  care  must  be  exercised  to  avoid 
laceration,  as  under  no  circumstances  are  extensive  ruptures  of  the 
lower  uterine  segment  so  apt  to  follow  as  in  the  forcible  extraction 
of  the  after-coming  head.  The  introduction  of  a  large-sized  catheter 
into  the  child's  mouth  and  drawing  back  the  perinseum  have  been 
found  useful  as  temporary  means  of  introducing  air  into  the  child's 
lungs,  where  delay  attends  efforts  at  delivery. 

In  extracting  the  after-coming  head,  the  Tarnier  forceps  is  par- 
ticularly to  be  recommended. 


CHAPTER  XXI. 

VERSION. 

Cephalic  version. — External  method. — Combined  method. — Busch. — D'Outrepont. — 
Wright  — Hohl. — Braxton  Hicks. — Podalic  version. — Bi-polar  method. — Internal  ver- 
sion.— Neglected  version, — Use  of  the  fillet. 

Version",  or  turning,  is  the  term  employed  for  the  operations  by 
means  of  which  an  artificial  change  is  effected  in  the  presentation  of 
the  child.  It  comprises  the  substitution  of  one  pole  of  the  foetus  for 
the  other,  and  the  conversion  of  an  oblique  or  shoulder  presentation 
into  one  in  which  the  long  axis  of  the  foetus  corresponds  to  the  verti- 
cal axis  of  the  uterus. 

It  is  customary  to  designate  specifically  the  character  of  the  version 
by  mentioning — 1.  The  presentation  to  be  changed.  Thus,  version  is 
made  from  the  head,  the  breech,  or  the  shoulder,  as  the  presenting 
part.  2.  The  presentation  to  be  effected.  The  term  cephalic  version 
is  used  where  the  head  is  brought  to  the  brim  of  the  pelvis,  and  po- 
dalic version  where  the  feet  are  seized  and  the  extremities  made  the 
presenting  part.  3.  The  method  adopted  by  which  version  is  accom- 
plished. The  expression  external  version  is  applied  to  manipulations 
exclusively  through  the  abdominal  walls  ;  internal  version,  to  the  in- 
troduction of  the  entire  hand  into  the  uterus  ;  and  the  combined 
method  to  cases  in  which  both  hands,  the  one  externally  and  the  other 
with  two  to  four  fingers  introduced  through  the  os,  cooperate  together. 

Cephalic  Version. — When  it  is  simply  required  to  rectify  a  faulty 
presentation  (shoulder  or  transverse),  without  reference  to  modify- 
ing circumstances,  cephalic  version  unciuestionably  deserves  the  pref- 
erence.   In  practice,  however,  this  method  requires  the  concurrence 


VERSION. 


367 


of  so  many  favorable  conditions  that  its  employment  is  very  limited. 
For  instance,  there  must  be  no  complications  which  call  for  rapid 
delivery.  It  would  be  unsuitable  in  prolapse  of  the  cord  and  in 
cases  of  placenta  praevia.  There  should  be  nothing  to  prevent  the 
child's  head  from  entering  the  brim  of  the  pelvis.  It  should,  there- 
fore, not  be  attempted  in  contracted  pelves.  A  prolapsed  arm,  unless 
previously  replaced,  would  render  the  operation  impossible.  The 
child  should  enjoy  a  considerable  degree  of  mobility.  An  abundance 
of  amniotic  fluid  contributes  much,  though  it  is  not  indispensable,  to 
success,  as,  even  after  the  rupture  of  the  membranes,  provided  the 
uterine  walls  are  sufficiently  relaxed,  the  head  may  be  brought  into 
the  pelvis.  Before  rupture,  excessive  sensitiveness  to  manipulations, 
and,  after  rupture,  rigidity  of  the  uterus  stand  in  the  way  of  success. 

The  operation  may  be  performed  by  either  the  external  or  the  com- 
bined method. 

Of  the  external  methods  the  best  is  that  which  is  known  as  Wi- 
gand's  (1807),  which  combines  a  suitable  position  of  the  mother,  with 
manipulations  through  the  abdominal  w^alls.  The  mother  is  at  first 
made  to  lie  upon  her  back,  with  knees  flexed,  and  with  the  abdomen 
exposed  or  covered  by  some  light  material.  The  physician  stands  by 
the  side  of  the  patient,  looking  in  the  direction  of  her  face.  He  be- 
gins by  laying  his  hands  flat  upon  the  surface  of  the  abdomen,  and 
seeks  with  the  one  the  head  and  with  the  other  the  breech  of  the  foetus. 
During  the  intervals  of  the  pains,  by  gentle  movements  of  the  two 
hands  working  simultaneously,  he  strives  to  press  up  the  breech  and 
anterior  surface  of  the  child  and  to  bring  the  head  into  the  pelvic 
brim.  Should  the  uterus  harden,  all  friction  movements  of  the 
hands  should  cease,  and  the  efforts  of  the  operator  be  confined  to 
holding  the  foetus  steady  in  the  position  previously  produced.  The 
movement  may  be  aided  by  turning  the  woman  upon  the  side  toward 
which  the  head  is  directed.  As  the  fundus  of  the  uterus  sinks  to  the 
side  upon  which  the  woman  lies,  it  carries  the  breech  of  the  child 
with  it,  while  the  change  in  the  uterine  axis  tends  to  throw  the  ce- 
phalic end  in  the  oj)posite  direction. 

When  the  head  is  once  brought  to  the  brim  of  the  pelvis  it  may  be 
retained  i7i  situ,  if  the  patient  lies  upon  her  side,  by  the  hand  of  an 
assistant,  or  by  a  small,  hard  pillow  pressed  firmly  against  it.  If  the 
patient  lies  upon  the  back,  two  compresses  may  be  laid  along  the  sides 
of  the  uterus  near  the  head,  and  a  bandage  applied  to  the  abdomen  to 
keep  them  in  position.  When  the  pains  are  regular  and  the  cervix 
partially  dilated,  fixation  of  the  head  may  be  accomplished  by  ruptur- 
ing the  membranes  and  allowing  the  waters  to  escape.  Until  the  uterus 
retracts  down  upon  the  child,  the  head  should  be  held  at  the  brim  either 
by  the  two  hands  through  the  abdominal  walls,  or  by  the  thumb  and 
four  fingers  of  one  hand  applied  directly  to  the  head  through  the  cervix. 


368 


OBSTETRIC  SURGERY. 


The  more  important  of  the  combined  methods  are  those  of  Busch, 
D'Outrepont,  Wright,  Hohl,  and  Braxton  Hicks.  They  have  in  com- 
mon the  simultaneous  employment  of  the  external  and  internal  hand. 
They  differ,  however,  in  detail.  The  methods  of  Busch  and  D'Outre- 
pont  have  now  chiefly  an  historical  interest.  Busch  introduced  the 
hand  corresponding  to  the  child's  head  through  the  vagina  and  cervix, 
w^hile  counter-pressure  was  made  with  the  other  hand  upon  the  fundus 


uteri.  The  back  of  the  hand  is  at  first  directed  to  the  front.  When, 
however,  its  widest  portion  has  passed  above  the  symphysis  pubis,  the 
back  of  the  hand  is  turned  to  the  concavity  of  the  sacrum,  and  the  fin- 
gers are  pushed  up  with  care  between  the  membranes  and  the  uterus  to 
the  head.  The  membranes  are  then  ruptured,  and  during  the  escaj^e  of 
the  waters  the  head  is  seized  by  the  fingers  and  thumb  and  drawn  into 
the  pelvis,  while  the  disengaged  hand  presses  the  breech  toward  the 
median  line.  Every  pains  should  be  taken  to  prevent,  with  the  fingers, 
the  prolapse  of  the  cord,  or  of  an  arm,*  during  the  escape  of  the 
water.  J3'Outrepont  seized  the  presenting  shoulder  between  the  thumb 
and  fingers  of  the  hand  corresponding  to  the  breech,  and,  during  the 
intervals  between  the  pains,  pushed  the  shoulder  upward  and  in  the 
direction  of  the  breech  until  the  head  descended  into  the  pelvis. 
During  this  manceuvre,  D'Outrepont  simply  used  the  external  hand 
to  support  the  uterus.  Scanzoni  recommended  tliat  it  should  be  em- 
ployed externally  to  press  the  head  toward  the  pelvic  brim.f 

Wright's  method  differs  from  that  of  D'Outrepont,  in  that  he  em- 
ployed, to  seize  the  shoulder,  the  hand  corresponding  to  the  liead,  and, 
while  he  pushed  tlie  shoulder,  without  lifting,  in  tlie  direction  of  the 
*  Scanzoni,  "Lohrbuch  der  Geburtsliiilfe,"  18G7,  Bd.  iii,  p.  G3.       f  Op.  cit.,  p.  65. 


Fig.  107. — D'Outrepont's  method,  modified  by  Scanzoni. 


VERSION. 


369 


curve  of  the  uterus,  he  applied  the  remaining  hand  to  dislodge  the 
breech  and  move  it  toward  the  center  of  the  uterine  cavity.* 

All  the  foregoing  methods  require  for  their  successful  performance 
a  movable  foetus  and  a  dilated  cervix,  conditions  which  render  podalic 
version  safe  and  of  easy  execution.  In  practice,  therefore,  they  have 
never  enjoyed  any  considerable  degree  of  popularity.  Of  far  greater 
importance  are  the  methods  of  Hohl  and  Braxton  Hicks,  which,  pos- 
sessing the  advantage  of  requiring  the  introduction  of  two  fingers  only 
into  the  uterus,  can  consequently  be  resorted  to  at  an  early  stage  of 
labor.  Hohl,  like  Wright,  employed  for  internal  use  the  hand  corre- 
sponding to  the  head.  With  two  fingers  in  the  cervix,  he  pushed  the 
top  of  the  shoulder  in  the  direction  of  the  breech,  and  pressed  the 
head  into  the  pelvis  with  the  external  hand.  At  the  same  time  he  in- 
trusted to  an  assistant  the  task  of  seizing  the  fundus  of  the  uterus 
between  the  palms  of  the  hands,  and  directing  it  to  the  side  toward 
which  the  head  was  turned,  f  Braxton  Hicks  describes  his  method  as 
follows  :  ^'  Introduce  the  left  hand  into  the  vagina  as  in  podalic  ver- 
sion ;  place  the  right  hand  on  the  outside  of  the  abdomen,  in  order 
to  make  out  the  position  of  the  foetus  and  the  direction  o±  the  head 
and  feet.  Should  the  shoulder,  for  instance,  present,  then  push  it, 
with  one  or  two  fingers  on  the  top,  in  the  direction  of  the  feet.  At 
the  same  time  pressure  by  the  outer  hand  should  be  exerted  upon  the 
cephalic  end  of  the  child.  This  will  bring  down  the  head  close  to  the 
OS ;  then  let  the  head  be  received  upon  the  tips  of  the  inside  fingers. 
The  head  will  play  like  a  ball  between  the  hands,  and  can  be  placed  in 
almost  any  part  at  will.  .  .  .  It  is  as  well,  if  the  breech  will  not  rise 
to  the  fundus  readily  after  the  head  is  fairly  in  the  os,  to  withdraw 
the  hand  from  the  vagina  and  with  it  press  up  the  breech  from  the 
exterior. "  I  Lately,  Hicks  has  proposed  to  employ  the  external  hand 
to  alternately  press  the  head  into  the  os  and  the  breech  to  the  fundus. 
His  plan  differs  from  that  of  Hohl,  in  that  he  operates  with  the  patient 
upon  the  side,  and  uses  the  left  hand  with  the  patient  upon  the  left 
side,  and  the  right  hand  when  she  lies  upon  the  right.  He  likewise  dis- 
penses with  an  assistant.* 

Podalic  Version". 

Podalic  version  is  indicated  in  the  following  cases  : 

1.  The  transverse  presentation,  where  cephalic  version  is  contra- 
indicated,  or  attended  with  any  considerable  degree  of  difficulty. 

2.  In  head  presentations,  where  there  is  reason  to  suppose  that  the 

*  Wright,  "Am.  Jour,  of  Obstet.,"  vol.  vi,  part  1,  ISYS. 

f  IIoiiL,  "Lehrbuch  dcr  Geburtshiilfe,"  2te  Auflagc,  1862,  p.  784. 
X  IIiCKS,  "  Combined  External  and  Internal  Version,"  "  Trans,  of  the  Obstet.  Soc.  of 
London,"  vol.  v,  p.  230. 

*  UiCKS,  "Am.  Jour,  of  Obstet.,"  July,  1879,  p.  593. 

24 


370 


OBSTETRIC  SURGERY. 


result  would  be  favorably  influenced  by  bringing  down  the  feet.  As 
illustrations  of  such  conditions,  we  have  faulty  presentations  of  the 
head  and  face,  prolapse  of  the  cord  and  extremities,  placenta  prsevia, 
and  contracted  pelvis.  The  various  contingencies  which  call  for  ver- 
sion will  be  more  closely  considered  in  connection  with  the  special 
morbid  conditions  mentioned. 

The  operation  may  be  performed  by  combined  external  and  inter- 
nal manipulations,  or  by  the  internal  hand  alone. 

The  Bi-polar  or  Combined  Method  of  Braxton  Hicks.— In  the  bi- 
polar method  of  turning,  the  two  hands  operate  simultaneously  upon 
the  extremities  of  the  foetus.  It  may  be  carried  out  at  will  with  the 
patient  upon  the  side  or  upon  the  back.  The  latter  position  is  the 
one  which  finds  most  favor  in  this  country.  The  patient  should  be 
placed  transversely  in  the  bed  and  the  nates  drawn  to  the  edge.  Two 
assistants  are  required  to  hold  the  legs,  which  should  be  flexed  and  ro- 
tated outward.  As  the  beds  in  America  are  very  low,  where  difficulty 
in  operating  is  anticipated  it  is  sometimes  advisable  to  remove  the 
joatient  after  she  has  been  anaesthetized  to  a  table  covered  with  a  blan- 
ket or  woolen  comforter.  Complete  anaesthesia  is  useful  as  a  means 
of  facilitating  the  introduction  of  the  internal  hand,  and  maintaining 
a  relaxed  condition  of  the  uterus.  Care  should  be  taken  that  both 
bladder  and  rectum  are  emptied.  The  hand  selected  for  internal 
manipulations  should  be  of  the  same  name  as  the  side  to  which  the 
the  extremities  are  turned — i.  e.,  feet  to  the  right,  right  hand  ;  feet  to 
the  left,  left  hand.*  The  fingers  should  be  brought  together  in  the 
form  of  a  cone.  The  back  of  the  hand  and  forearm  should  be  well 
lubricated  with  oil  or  lard.  In  passing  the  hand  into  the  vagina,  the 
labia  should  be  separated  by  the  thumb  and  fingers  of  the  disengaged 
hand.  Entrance  is  effected  by  directing  the  fingers  toward  the  sa- 
crum, and  pressing  backward  upon  the  distensible  perinaeum.  In  this 
stage  of  the  procedure  hasty  action  is  out  of  place.  Patience  and  gen- 
tleness are  the  prime  requisites.  Two  or  three  fingers  only  need  to  be 
carried  through  the  internal  os.  When  the  joresenting  part  is  reached, 
the  external  hand  should  be  laid  upon  the  abdomen,  and  pressure 
brought  to  bear  upon  the  breech.  The  two  hands  should  then  move  the 
extremities  of  the  child  in  opposite  directions.  To  quote  Dr.  Barnes, 
''The  movements  by  which  this  is  effected  are  a  combination  of  con- 
tinuous pressure  and  gentle  impulses  or  taps  with  the  finger-tips  on 
the  head  (or  shoulder),  and  a  series  of  half-sliding,  half-pushing  im- 
pulses with  the  palm  of  the  hand  outside."  When  the  breech  is  well 
pressed  down  to  the  iliac  fossa,  the  membranes  should  be  ruptured 

*  In  England  the  patient  is  dclivei'ed  upon  the  left  side,  and  the  left  hand  is  com- 
monly introduced  into  the  vagina.  In  Germany,  when  the  patient  lies  upon  the  right 
side,  the  left  hand  is  employed  inside ;  when  upon  the  left  side,  the  right  hand.  The 
choice  of  hands,  it  will  be  seen,  is  not  a  matter  of  considerable  importance. 


VERSION. 


371 


during  a  pain,  and  a  knee,  wliich  at  this  time  is  generally  near  the  os 
internum,  should  be  seized  and  hooked  into  the  vagina  with  the 
fingers.  As  the  breech  is  brought  into  the  pelvis  by  tractions  upon  the 
leg,  the  outer  hand  should  be  employed  to  press  up  the  head  until  the 
version  is  completed. 

The  manipulations  described  are  to  be  conducted  during  the  inter- 
vals between  the  pains.  Care  should  be  taken  not  to  hook  down  the 
cord  with  the  knee.  When  the  lower  extremities  are  reflected  upward 
upon  the  body  so  that  a  knee  is  not  attainable,  the  breech  may  often 
be  brought  down  by  a  finger  inserted  into  the  fold  of  the  thigh,  or  by 
pressure  upon  some  part  of  the  pelvis. 

The  combined  method  of  version,  which  we  owe  in  all  its  essential  " 
features  to  Braxton  Hicks,  is  one  of  the  most  important  contributions 
to  obstetrical  practice  of  the  present  century.  It  possesses  the  price- 
less advantages  of  enabling  the  physician  to  j)erform  version  early  in 
labor,  and  to  accomplish  the  operation  without  in  any  way  imperiling 
the  integrity  of  the  uterus.  The  only  prerequisites  for  success  are  : 
sufficient  dilatation  of  the  cervix  to  permit  the  passage  of  two  fingers, 
a  certain  degree  of  fetal  mobility  within  the  uterine  cavity,  and  a 
precise  knowledge  of  the  fetal  position.  After  rupture  of  the  mem- 
branes and  escape  of  the  waters  the  operation  becomes  more  difficult, 
but  is  even  then  not  always  impracticable. 

Internal  Version. — In  internal  version  the  entire  hand  is  introduced 
into  the  uterus.  It  is  necessary,  tlierefore,  that  the  cervix  should  be 
so  far  dilated  that  the  hand  can  be  passed  without  violence  through 
the  cervical  canal.  Irregular  uterine  contractions  require  to  be  re- 
lieved by  hypodermic  injections  of  morphia,  with  or  without  the  addi- 
tion of  atropia,  or  by  the  induction  of  complete  anaesthesia.  As  inter- 
nal version  is  not  an  indifferent  operation,  but  may  be  followed  by 
inflammations  due  either  to  injuries  of  the  maternal  tissues  or  to  the 
introduction  of  infected  air  into  the  uterus,  it  should  not  be  attempted 
until  the  impracticability  of  the  combined  method  has  been  demon- 
strated. It  is  applicable  chiefly  to  cases  in  which  a  certain  degree  of 
uterine  retraction  has  followed  upon  the  escape  of  the  amniotic  fluid.* 

The  patient  should  be  placed  upon  the  back  or  side  ;  the  bladder 
and  rectum  should  be  emptied  ;  and  anaesthesia  should  be  pushed 
until  the  action  of  the  abdominal  muscles  is  suspended.  The  exact 
position  of  the  foetus  should  be  carefully  ascertained.  The  hand,  well 
oiled  upon  its  dorsal  aspect,  should  be  passed  slowly,  after  the  expira- 

*  If  the  membranes  are  intact,  and  internal  version  is  chosen  in  place  of  the  bi-polar 
method,  one  of  three  plans  is  open  in  practice:  1.  Boer  recommended  passing  the  hand 
between  the  membranes  and  uterus  to  the  feet  of  the  child,  and  then  rupturing  the  mem- 
branes ;  2.  Hiiter  seized  the  feet  of  the  child  through  the  membranes,  and  turned  without 
rupturing ;  3.  Levret  ruptured  the  membranes  at  the  os  uteri,  and  introduced  the  hand 
during  the  outflow  of  the  water.    The  third  plan  is  the  one  most  deserving  of  favor. 


372 


OBSTETRIC  SURGERY. 


tion  of  a  pain,  with  the  fingers  formed  into  a  cone,  through  the  vagina 
and  cervix,  opposite  the  sacro-iliac  synchondrosis,  upon  the  side  of  the 
child's  feet.  At  the  same  time  counter-pressure  should  be  maintained 
over  the  fundus  uteri,  to  prevent  rupture  of  the  vaginal  attachments. 
If  the  uterus  begins  to  contract,  the  fingers  should  be  spread  out,  and 
the  operator  remain  passive  until  the  pain  subsides. 

In  head  presentations,  the  hand  employed  should  be  always  the  one 
which  corresponds  to  the  side  of  the  child's  feet.  In  transverse  presen- 
tations, when  version  is  performed  soon  after  the  ruj)ture  of  the  mem- 
branes, before  retraction  of  the  uterus  has  taken  place  to  any  ex- 


FiG.  168.-yersion  in  head  presentations.     ^j^g  J^^nd,  and  the  pointed  heel  to 


In  the  lateral  position,  the  patient  should  be  placed  upon  the  side 
to  which  the  child's  breech  is  turned,  with  the  buttocks  near  the 
edge  of  the  bed.  Here,  obviously,  the  operator,  standing  in  the 
rear  of  his  patient,  would  use  with  the  greatest  facility  the  hand 
corresponding  to  the  side  upon  which  the  woman  lies  (left  side,  right 
hand,  and  vice  versa).  In  dorso-posterior  positions,  especially,  the  ad- 
vantages of  such  a  selection  are  manifest. 

In  easy  versions,  it  is  correct  practice  to  bring  down  one  foot  or 
knee  only.    When  one  extremity  is  left  reflected  upon  the  abdomen. 


tent,  the  choice  of  hands  is  of  lit- 
tle consequence.  This  is  especial- 
ly true  in  the  dorso-anterior  posi- 
tion. Thus,  when  the  child  lies 
with  the  head  to  the  left,  feet  to 
the  right,  and  belly  to  the  rear, 
the  right  hand  may  be  passed  di- 
rectly across  the  belly  to  the  ex- 
tremities of  the  child,  or  the  left 
hand  may  be  made  to  pass  from 
the  breech,  along  the  surface  of 
the  thigh,  to  the  nearest  knee  or 
leg.  By  the  latter  method  the 
danger  of  mistaking  an  arm  for 
the  leg  is  avoided.  Should,  in  any 
case,  doubt  upon  this  score  arise, 
the  characteristic  differences  be- 
tween the  hand  and  foot  should 
guide  us  to  a  correct  diagnosis. 
Thus,  the  wrist  enjoys  greater  mo- 
bility than  the  ankle,  the  fingers 
are  longer  than  the  toes,  the  palm 
is  shorter  than  the  sole,  the  posi- 
tion of  the  thumb  is  peculiar  to 


the  foot. 


VERSION. 


373 


tlie  larger  size  of  the  breecli  more  fully  distends  the  cervix,  and  thus 
prepares  the  way  for  the  subsequent  passage  of  the  child's  head.  In 
difficult  cases,  or  when  rapid  delivery  is  to  be  effected,  both  feet  should 
be  seized.  A  single  foot  should  be  held  at  the  ankle  between  the 
thumb  and  fingers.  When  practicable,  the  entire  leg  may  be  grasped 
with  the  closed  hand.  AVhen  it  is  sought  to  turn  by  both  feet,  the 
middle  finger  should  be  placed  between  them,  while  the  ankles  are 
held  by  the  second  and  fourth  fingers. 

Little  importance  should  be  attached  to  the  question  as  to  which 
extremity  should  be  selected,  so  long  as  the  version  is  uncomplicated. 
While  in  Germany  preference  is  accorded  to  the  seizure  of  the  lower 
extremity,  the  superiority  of  turning  by  the  more  remote  limb  is  gen- 
erally advocated  in  England. 

As  in  the  bi-polar  method,  during  the  traction  upon  the  foot,  the 


Figs.  169, 170. — Version  in  transverse  presentations ;  direct  method  of  seizing  feet.  (Braun.) 


external  hand  should  aid  version  by  pressure  upward  upon  the  head 
made  through  the  abdominal  walls  with  the  disengaged  hand. 

When,  in  transverse  presentations,  the  membranes  rupture,  the 
lower  arm  not  unfrequently  becomes  prolapsed  into  the  vagina.  As  a 
rule,  this  complication  does  not  embarrass  version,  though  it  may  prove 
a  hindrance  to  the  introduction  of  the  hand.  It  is  a  good  plan,  in 
arm-presentations,  to  slip  a  noose  of  tape  about  the  wrist,  which  serves 
a  twofold  purpose,  enabling  us  to  draw  the  extremity  up  toward  the 
symphysis,  or  back  against  the  perinseum,  according  as  the  hand  is  to 
be  passed  posteriorly  or  anteriorly,  and  to  hold  the  arm  to  the  side  of 
the  child's  body  during  the  performance  of  version,  thus  avoiding  the 


374 


OBSTETRIC  SURGERY. 


difficulties  of  arm  delivery  in  the  period  of  extraction.  Dr.  F.  P. 
Foster,  in  a  case  where  the  mobility  of  the  child  was  unimpeded,  used 
the  prolapsed  arm  as  an  aid  to  version  in  the  following  ingenious 
manner  :  The  child  lay  with  the  back  to  the  front,  the  head  upon  the 
right  iliac  fossa,  and  the  left  arm  presenting.  With  the  right  hand  in 
the  vagina,  he  seized  the  arm,  and  pushed  gently  upward  in  the 
direction  of  the  humerus.  In  this  way  he  succeeded  in  elevating 
the  cephalic  pole  until  with  the  index  -  finger  alone  in  the  cervix 
uteri  he  managed  to  reach  the  breech  of  the  child.  With  the  point 
of  his  finger  he  gently  urged  this  along  to  the  mother's  right  side. 


Fig.  171. — Method  of  reacMng  an  extremity  by  first  passing  the  hand  around  the  breech. 

(Scanzoni.j 

and  soon  encountered  the  left  foot,  which  he  readily  hooked  down 
into  the  vagina.* 

When,  after  rupture  of  the  membranes,  aid  is  not  promptly  ren- 
dered, the  shoulder  becomes  crowded  into  the  pelvic  brim.  If  the 
pains  are  feeble  the  uterus  may  remain  relaxed,  so  that  hours  after- 
ward version  may  be  readily  performed.  If  the  pains  are  good,  how- 
ever, as  the  waters  escape  the  uterus  retracts,  until  finally  it  becomes 
rigidly  applied  to  the  surface  of  the  foetus.  This  condition  is  known 
to  obstetricians  as  a  neglected  shoulder  presentation.  Version,  under 
the  circumstances,  is  embarrassed,  partly  by  the  difficulty  of  intro- 
ducing the  hand  into  the  uterus  to  seize  the  foot,  and  partly  by  the 
fact  that  when  tractions  are  made  wpon  an  extremity,  in  place  of  the 

*  Foster,  "  On  Prolapse  of  the  Arm  in  Transverse  Presentations,''  "  Amcr.  Jour, 
of  Obstet.,"  vol.  ix,  p.  203. 


VERSION. 


875 


child  turning  in  idero,  both  child  and  the  closely  applied  uterus  are 
apt  to  move  together. 

In  operating  after  the  retraction  of  the  uterus  has  become  com- 
plete, the  physician  should  seek  to  effect  the  utmost  relaxation  by 
pushing  anaesthesia  to  complete  insensibility.  The  hand  should  be 
introduced  slowly  and  with  the  utmost  gentleness.  Precipitate  action, 
or  an  attempt  to  overcome  the  uterine  resistance  by  force,  may  cause 
fatal  rupture.  The  external  hand  should  make  firm  counter-pressure 
upon  the  fundus,  to  prevent  the  uterus  from  being  torn  from  the 
vagina.  The  seizure  of  the  lower  foot  is  usually  alone  practicable. 
Simpson,  it  is  true,  regarded  the  secret  of  success  in  such  cases  as 
depending  \v^oi\  making  tractions  with  the  upper  limb,  as  tending  to 
rotate  the  body  of  the  child  upon  its  long  axis,  and  thus  favoring  the 
release  of  the  presenting  shoulder  from  its  imprisonment.  However 
rational  all  this  sounds  in  theory,  rotation  within  a  rigidly  contracted 
uterus  is  easier  to  represent  by  diagram  than  to  carry  out  in  practice. 
The  result  of  seizing  the  upper  leg  is  usually  to  cross  it  with  its  fellow, 
and  to  twist  the  child's  body  so  as  to  injuriously  compress  the  abdom- 
inal viscera.  By  making  tractions  upon  the  lower  leg,  the  breech  is 
brought  by  the  shortest  route  to  the  uterine  orifice.  To  be  sure,  by 
this  manoeuvre  the  body  of  the  child  is  bent  laterally,  but  lateral 
flexion  does  the  child  no  harm.  In  case  of  failure  to  effect  version, 
a  noose  of  tape  may  be  placed  upon  the  foot,  and  the  hand  returned 
to  seek  the  other  extremity.  When  the  foot  is  within  reach,  the 
loop  of  the  fillet,  placed  about  the  fingers,  is 
easily  conveyed  upward  to  the  ankle.  When, 
however,  the  foot  is  high  uj)  in  the  vagina, 
where  the  movement  of  the  fingers  is  im- 
peded, some  form  of  instrument  is  needed  to 
push  the  loop  from  the  fingers  over  the  foot. 
Unquestionably  the  most  serviceable  contriv- 
ance to  this  end  is  the  repositor  of  Carl  Braun, 
which  consists  of  a  gutta-percha  rod,  sixteen 
inches  in  length,  with  an  aperture  two  inches 
from  the  extremity,  through  which  the  loop 
of  a  doubled  tape  is  threaded.  When  in  use 
this  loop  is  passed  around  the  noose  of  the 
fillet,  and  is  then  reflected  over  the  end  of  the 
rod.  Thus  secured,  the  fillet  is  conveyed  to 
the  position  aimed  at.  Then  by  loosening 
the  ends  of  the  tape,  which  during  the  upward 
movement  are  held  to  the  sides  of  the  rod  by 
the  operator's  hand,  and  by  shaking  the  rod,  the  instrument  is  easily 
detached,  and  can  be  withdrawn  without  difficulty. 

If  the  operator  docs  not  care  to  release  the  foot,  because  of  the 


Fig.  172 


aun's  repositor. 


376 


OBSTETRIC  SURGERY. 


diflficulties  he  has  encountered  in  getting  possession  of  it,  the  fillet  may- 
be noosed  around  his  arm,  and  thence  be  pushed  upward  over  the 
hand,  to  the  seized  extremity. 

A  device,  which  in  many  instances  has  rendered 
Jf' ^  me  excellent  service,  has  consisted  of  an  ordina- 

I    '  ry  catheter  threaded  with  a  doubled  piece  of  twine, 

so  that  the  loop  projected  from  the  eye  of  the  in- 
strument. This  loop,  after  inserting  the  stylet 
into  the  catheter,  I  have  used  in  precisely  the 
manner  laid  down  for  the  employment  of  Braun's 
instrument. 

In  case  the  second  limb  can  not  be  reached,  or 
where  traction  upon  both  extremities  fails  to  bring 
the  breech  into  the  cervix,  an  attempt  should 
be  made  to  dislodge  and  elevate  the  presenting 
shoulder.  This  can  sometimes  be  accomplished, 
in  accordance  with  the  suggestion  of  Professor 
Goodell,  by  bringing  down  the  upper  arm,  and 
turning  the  child  upon  its  long  axis ;  or,  while 
the  noosed  foot  is  held  out  of  the  way  by  the  at- 
tached fillet,  the  hand  corresponding  to  the  child's 
head  may  be  introduced  into  the  vagina,  and  em- 
ployed to  press  the  presenting  part  away  from  the  cervix.  The 
raising  of  the  shoulder  should  be  gradual,  and  should  be  performed 
with  the  utmost  gentleness,  as  the  danger  of  uterine  rupture  is  pecu- 
liarly enhanced  by  the  thinned,  overstretched  condition  of  the  lower 
segment.  Meantime  a  skilled  assistant  should  support  the  uterus 
from  without,  and  aid  the  descent  of  the  breech  by  rightly  directed 
pressure.  Resolution  to  succeed,  combined  with  patience  in  manipu- 
lation, usually  overcomes  the  obstacles  presented  by  the  most  difficult 
cases. 

In  the  few  instances  where  failure  follows  all  attempts  to  accom- 
plish version,  or  where  rupture  is  imminent,  or  where  the  child  is 
known  to  be  dead,  the  obstacle  to  delivery  may  be  overcome  by 
decapitation,  and  the  removal  of  the  head  and  trunk  separately. 


Fig.  173.— Catheter  used 
as  repositor. 


CRANIOTOMY  AND  EMBRYOTOMY. 


377 


CHAPTER  XXII. 

CRANIOTOMY  AND  EMBRYOTOMY. 

Craniotomy. — Indications. — Operation. — Perforators. — Method  of  perforating. — Extrac- 
tion after  perforation. — Forceps. — Cephalotribe. — Action  of  the  cephalotribo. — Ob- 
jections.— Application  of  the  cephalotribe. — Cranioclast. — Crotchet  and  blunt  hook. 
— Cephalotomy. — Embiyotomy. — Exenteration. — Decapitation. 

Craj^iotomy. 

Craxiotomy  includes  all  the  various  operations  employed  to 
reduce  the  dimensions  of  the  child's  head.  Thus  the  term  is  applied 
— 1.  To  the  perforation  of  the  skull,  and  the  evacuation  of  the  brain- 
contents  ;  and,  2.  To  the  various  procedures  subsequently  adopted 
to  further  minimize  and  extract  the  cranial  walls. 

Indications  for  Perforation. — Perforation  is  resorted  to,  in  cases  of 
mechanical  obstacles  to  delivery,  to  overcome  the  disproportion  exist- 
ing between  the  child's  head  and  the  parturient  canal.  As  the  opera- 
tion is  performed  solely  in  the  interests  of  the  mother,  it  possesses  a 
wider  range  of  applicability  when  the  child  is  dead  than  when  still 
living. 

Perforation,  in  the  dead  child,  is  allowable  in  difficult  labors  so 
soon  as  temporizing  becomes  dangerous  to  the  mother.  The  mere 
aesthetic  advantage  of  removing  by  forceps  an  unmutilated  child 
ought  not,  if  attended  by  any  risk,  to  be  allowed  to  weigh  with  the 
physician  against  the  welfare  and  safety  of  the  parent. 

If  the  child  is  alive,  the  question  of  perforation  is  one  of  the  most 
serious  that  falls  to  the  lot  of  the  conscientious  physician.  If  the  life 
of  the  mother  is  at  stake,  and  the  sacrifice  of  the  child  is  necessary  to 
her  preservation,  few  w^ould  dispute  at  the  present  day  the  superiority 
of  the  mother's  claim  to  existence.  Still,  it  is  not  sentimentality  to 
feel  that  it  is  an  awful  thing  to  destroy  a  living  child  before  a  clear 
conviction  is  reached  that  conservative  measures,  which  hold  out  the 
hope  of  preserving  both  lives,  are  of  little  or  no  avail.  The  proper 
position,  however,  of  craniotomy,  between  the  Csesarean  section  on  the 
one  hand  and  forceps  and  version  upon  the  other,  will  be  discussed 
in  the  section  upon  the  treatment  of  contracted  pelves. 

Operation. — When  perforation  has  once  been  decided  upon,  there 
should  be  no  delay  in  its  execution.  By  delay,  the  very  object  of  its 
performance,  viz.,  the  preservation  of  the  life  of  the  mother,  is  im- 
periled.* 

The  patient  should  be  placed  in  the  usual  obstetrical  position, 

*  Spiegelberg  states  that  between  the  years  1870  and  1877,  of  thirty-three  cases  of 
perforation,  three  terminated  fatally,  while  in  the  previous  five  years  in  which  the  opera- 
tion was  performed,  at  a  late  period,  of  thirteen  cases,  seven  ended  in  death. — ("Hand- 
buch  dor  Gcburtshiilfe,"  p.  833.) 


378 


OBSTETRIC  SURGERY. 


with  the  knees  flexed,  and  the  hips  drawn  over  the  edge  of  the  bed. 
Chloroform  is  not  requisite.  It  is  useful,  however,  as  a  means  of  sav- 
ing the  mother  from  painful  after-memories.  If  the  head  is  not  fixed 
at  the  brim,  it  should  be  held  firmly  in  position  by  the  hands  of  an 
assistant,  through  the  abdominal  Avails,  or  the  child  should  be  turned, 
and  perforation  performed  on  the  after-coming  head. 

Complete  dilatation  of  the  cervix  is  not  essential  to  the  execution 
of  the  operation.  If  the  object  is  simply  to  relieve  the  maternal  soft 
parts  from  pressure,  perforation  may  be  performed  at  an  early  stage 
of  labor.  When,  however,  it  is  intended  to  follow  i^erforation  by 
immediate  extraction,  it  is  necessary  to  secure  sufficient  preliminary 
dilatation.  In  just  this  class  of  cases  I  have  seen  excellent  results 
from  the  employment  of  Dr.  I.  E.  Taylor's  long,  narrow-bladed  for- 
ceps, which  can  be  passed  through  a  cervix  dilated  to  scarcely  an  inch 
and  a  half  in  diameter.  They  enable  the  operator  to  seize  the  head, 
and  use  it  as  a  dilating  wedge  during  and  after  a  pain  {vide  p.  350). 
If  the  cervix  hangs  empty  in  the  pelvis,  and  the  head  can  not  be 
moved  from  the  brim,  Barnes's  dilators  are  often  of  great  service. 
Unquestionably  in  many  cases  less  violence  is  done  to  the  mother,  if 
simple  perforation  is  resorted  to,  the  brain  evacuated,  and  the  dila- 
tation of  the  cervix  left  to  be  accomplished  by  the  pressure  of  the 
gradually  collapsing  head.  This  method,  however,  exposes  the  mother 
to  the  dangers  of  septic  poisoning,  as,  unless  the  pains  should  be  good 
and  delivery  rapid,  decomposition  of  the  foetus  in  iitero  speedily  sets 
in  after  perforation. 

Instruments  employed  in  Perforation. — Most  of  the  perforating 
instruments  in  use  in  this  country  are  patterned,  with  modifications, 
after  the  scissors  of  Smellie.  Simpson's  perforator  is  the  one  I 
have  been  in  the  habit  of  employing.  As  compression  of  the  han- 
dles causes  tlie  separation  of  the  perforating  points,  it  can-  be  easily 
managed  with  one  hand.  The  projecting  shoulders,  just  beneath 
the  cutting  portions,  prevent  the  instrument  from  penetrating  too  far 


Fig.  174.— Scissors  of  Smellie. 


into  the  skull.  Tlic  edges  and  points  of  the  blades  are  rounded,  so  that 
they  are  not  liable  to  injure  the  soft  parts  of  the  mother  during  the 
operation.  The  chief  objection  to  the  instrument  arises  out  of  these 
special  measures  of  safety,  as,  owing  to  its  bluntness,  considerable 


CRANIOTOMY  AND  EMBRYOTOMY. 


379 


force  has  to  be  employed  to  penetrate  the  skull,  which  increases,  of 
course,  the  risk  of  slipping.  A  better  instrument  is  that  of  Monsieur 
Blot.     It  possesses  a  spear-point,  which  makes  it  effective  as  a  per- 


FiG.  175. — Simpson's  perforator. 


forator.  The  blades,  when  the  instrument  is  shut,  are  superimposed, 
and  are  not  capable  of  harming  the  maternal  tissues.    When  the  blades 


Fig.  176. — Blot's  perforator. 

are  separated,  after  perforation  has  been  accomplished,  they  readily 
cut  the  bony  structure  of  the  skull.    Hodge's  craniotomy  scissors  can 


Fig.  177. — Hodge's  craniotomy  scissors. 


be  used  as  a  perforator,  and  afterward  to  cut  away  portions  of  bone. 
Dr.  T.  G.  Thomas  has  devised  a  perforator  with  a  gimlet-like  extrem- 
ity, which  is  intended  to  bore  its  way  into  the  skull.    The  opening  is 


Fig.  178. — Thomas's  perforator. 


380 


OBSTETraC  SURGERY. 


afterward  enlarged  by  a  knife  which  lies  concealed  and  guarded  in  the 
body  of  the  instrument  until  required  for  use.  Mechanically  consid- 
ered, Thomas's  perforator  is  beyond  reproach.  It  is,  however,  some- 
what more  ditBcult  to  keep  in  order  than  those  previously  mentioned. 

The  Germans  employ  for  the  most  part  a  long  trephining  perfo- 
rator, which  removes  circular  segments  from  the  scalp  and  the  skull. 


Fig.  179. — Trephine  perforator. 


The  trephine  leaves  behind  no  splintered  portions  of  bones,  and  makes 
an  opening  which  is  not  likely  to  close  from  overlapping  ;  but  it  can, 
on  the  other  hand,  be  used  only  upon  the  cranial  vault. 

Previous  to  practicing  craniotomy,  the  bladder  and  rectum  should 
be  emptied.  The  operator  introduces  his  middle  and  index  fingers  into 
the  vagina,  and  presses  them  firmly  against  the  most  accessible  por- 
tion of  the  child's  head.  Great  care,  at  this  stage,  should  be  exercised 
to  gain  an  exact  idea  of  the  situation  and  the  extent  of  the  dilatation 
of  the  cervix.  The  operator  then  seizes  the  handle  of  the  perforator 
in  the  right  hand,  and  passes  the  pointed  extremity,  under  the  guid- 
ance of  the  fingers  of  the  left  hand,  to  the  region  of  the  head  at  which 
it  has  been  decided  the  perforation  is  to  be  made.  If  convenient,  a 
suture  or  a  fontanelle  may  be  selected,  in  place  of  the  bony  table  of 
the  skull.  The  perforator  should  be  pressed  against  the  cranium  with 
a  boring  movement  until  the  cessation  of  resistance  warns  the  operator 
that  the  bony  incasement  has  been  traversed.  In  cases  where  the 
skull  is  unusually  thick  or  hard,  this  part  of  the  operation  may  prove 
a  matter  of  some  difficulty.  Care  should  be  taken  to  hold  the  instru- 
ment at  right  angles  to  the  point  of  perforation,  as  otherwise  it  is  apt 
to  glance  from  the  rounded  surface  of  the  head. 

If  the  head,  in  place  of  being  fixed  in  the  pelvis,  is  situated  high 
up,  every  precaution  should  be  taken  in  the  operation.  The  head 
should  be  pressed  firmly  against  the  brim  through  the  abdomen  by  an 
assistant.  The  perforator  should  follow  the  axis  of  the  superior  strait. 
The  point  selected  for  perforation  should  be  near  the  symphysis,  as 
the  instrument  is  then  much  less  liable  to  slip  than  if  carried  back- 
ward toward  the  promontory.  The  fingers  of  the  left  hand  should 
keep  constant  guard  upon  its  direction.  Oftentimes,  by  way  of  pro- 
tection, the  operator  introduces  the  entire  half-hand  into  the  vagina. 
After  the  perforator  has  penetrated  the  skull,  the  opening  should  be 


CRANIOTOMY  AND  EMBRYOTOMY. 


381 


enlarged  by  compressing  the  handles  and  separating  the  cutting 
blades  ;  then,  allowing  the  latter  to  close,  the  instrument  should  be 
semi-rotated,  and  a  second  cut  made  at  right  angles  to  the  first.  Be- 


FiG.  180, — Operation  for  perforating  the  child's  head. 


fore  withdrawing  the  perforator,  it  should  be  moved  about  freely  to 
break  up  the  brain-mass.  The  rapidity  and  completeness  of  the  col- 
lapse of  the  cranial  walls  are,  in  a  measure,  dependent  upon  the  com- 
pleteness of  the  evacuation  of  the  cranial  contents.  Care  too  should 
be  taken  to  pass  the  perforator  into  the  foramen  magnum  to  break  up 
the  medulla  oblongata,  and  thus  to  insure  the  death  of  the  child 
before  delivery.  Sometimes  it  is  advantageous  to  wash  out  the  brain- 
pulp  by  injecting  a  stream  of  water  into  the  cranial  cavity.* 

In  face  presentations  care  should  be  taken  to  pass  the  perforator 
through  the  frontal  bones,  or  through  an  orbit.    Where  neither  of 

*  Von  Weber  has  shown  that  no  cephalotribe  can  fully  decerebrate  a  perforated 
head,  in  general  only  the  small  part  of  the  brain  being  evacuated.  He  has  likewise  demon- 
strated that  a  greater  amount  of  compression  can  be  accomplished  in  case  of  a  fully  than 
a  partially  decerebrated  head.  The  head,  therefore,  that  has  been  fully  emptied  can  be 
more  easily  extracted  than  one  that  has  only  been  partially  deprived  of  its  contents. 


382 


OBSTETRIC  SURGERY. 


these  points  is,  however,  accessible,  it  is  possible  to  make  the  open- 
ing through  the  roof  of  the  mouth,  behind  the  nasal  fossae. 

The  perforation  of  the  after-coming  head  is  always  a  matter  of 
considerable  difficulty.  The  point  of  the  perforator  has  to  be  inserted 
obliquely  in  place  of  at  right  angles  to  the  skull,  and  therefore  is  more 
liable  to  glance.  On  theoretical  grounds  it  has  been  recommended  to 
insert  the  instrument  either  between  the  occiput  and  atlas,  or  through 
a  lateral  fontanelle.  In  practice,  however,  such  niceties  are  rarely 
observed.  The  operator  simply  passes  the  four  fingers  of  the  left 
hand  under  the  symphysis  pubis,  and,  while  the  feet  of  the  child  are 
drawn  downward  and  backward  by  an  assistant,  the  perforation  is 
made  at  any  point  behind  the  ear  at  which  the  manipulation  can  be 
most  easily  effected.  Chailly  recommends  hooking  down  the  chin  of 
the  child,  and  perforating,  as  in  face  presentations,  through  the  roof 
of  the  mouth.* 

The  trephine-perf orator  requires  to  be  pressed  firmly  and  steadily 
against  the  parietal  bone.  Sometimes,  when  a  large  scalj^-tumor 
exists,  it  is  necessary  to  make  a  preliminary  incision  through  the 
integuments.  The  trephine  is  not  liable  to  slip,  and  is  easily  man- 
aged ;  as  it  can  not  be  used  either  upon  the  after-coming  head  or  in 
face  presentations,  and  as  it  is  difficult  to  keep  clean  and  in  order,  the 
less  complicated  lance-pointed  instruments  have,  however,  enjoyed  the 
preference  in  all  countries  outside  of  Germany. 

Extraction  of  the  Child  after  Perforation.— Formerly,  after  per- 
foration, a  waiting  policy  was  by  many  thought  desirable.  Osborne, 
indeed,  recommended  that  at  least  thirty  hours  be  allowed  to  elapse 
before  delivery,  in  case  craniotomy  was  performed  upon  a  living  child. 
The  grounds  for  favoring  a  temporizing  policy  were  found  in  the 
softening  and  relaxation  of  the  sutures,  and  the  ease  with  which  flat- 
tening takes  place  after  putrefaction  has  once  set  in.  At  present, 
however,  it  is  customary  to  extract  so  soon  as  the  condition  of  the  os 
renders  it  safe  to  resort  to  the  necessary  operative  procedures.  This 
change  in  practice  results  from  altered  views  regarding  the  dangers 
due  to  mere  protraction  of  labor,  to  fear  of  septic  poisoning,  and 
finally  to  improved  methods  now  at  our  disposal  for  the  termination 
of  labor.  Extraction  may  be  performed  by  the  forceps,  the  cepha- 
lotribe,  the  cranioclast,  the  crotchet,  or  the  blunt  hook.  In  some 
cases  version  may  be  employed  with  success.  Each  instrument,  each 
method,  has  its  limitations,  and  its  range  of  applicability.  Usually,  in 
extreme  disproportion,  the  operator  finds  it  to  his  advantage  to  have 

*  Cohnstcin  recommends  cutting  down  upon  the  cervical  and  upper  dorsal  vertebra?, 
and  then  opening  into  the  spinal  canal  by  dividing  the  lamina;.  Through  the  opening  a 
silver  catheter  can  be  passed  to  the  cranial  cavity,  and  be  used  to  break  up  the  brain- 
mass,  which  should  be  washed  out  through  the  canal  by  injections  of  water. — ( Vide  "Ein 
neucs  Perforations  Verfahren,"  "  Arch.  f.  Gynaek.,"  Bd.  vi,  p.  505.) 


CRANIOTOMY  AND  EMBRYOTOMY. 


883 


at  hand  a  complete  equipment,  and  to  resort  at  different  stages  of 
delivery  to  a  succession  of  operative  manoeuvres.  The  acceptance  of 
single  measures  and  the  wholesale  condemnation  of  all  others  are  cal- 
culated in  difficult  cases  to  lead  to  embarrassment  and  failure.  A 
study,  therefore,  of  the  capacity  of  the  various  extractive  instruments 
employed  to  deliver  the  perforated  head  is  essential  to  the  formation 
of  correct  judgment  as  regards  practice. 

Forceps. — The  use  of  forceps  as  an  extractive  instrument,  after  per- 
foration, is  recommended  by  Tarnier  as  follows  :  "  As  the  application 
of  forceps  has  often  succeeded  in  our  hands,  we  do  not  hesitate  to  say 
that  it  is  a  good  operation,  applicable  above  all  to  cases  in  which  the 
pelvic  contraction  is  not  considerable.  The  forceps  possesses  the  ad- 
vantage of  being  in  the  hands  of  every  physician  ;  it  seizes  the  head 
firmly,  and,  by  pressing  the  handles  forcibly  together,  a  sufficient  evac- 
uation of  the  cerebral  contents  is  effected  to  secure  a  marked  flattening 
of  the  cranial  walls.  In  making  prudent  tractions,  one  often  succeeds 
in  extracting  the  head  without  any  harm  to  the  mother ;  the  danger 
begins  only  with  too  violent  tractions."*  These  remarks  apply,  how- 
ever, to  the  powerful  French  forceps,  which  is  capable  of  exerting 
considerable  compressive  force.  Hodge  has  found  his  forceps  useful 
under  similar  conditions,  f  The  short  handles  and  the  great  width 
between  the  blades,  in  the  English  forceps,  render  it  useless  as  a  trac- 
tor when  craniotomy  has  been  performed. 

Cephalotribe. — On  the  6th  of  June,  1829,  Baudelocque,  le  neveu, 
read  before  the  Institut  Royal  de  France  a  memoir  upon  a  new  method 
of  performing  embryotomy.  J;  He  first  pictured  the  dangers  incident 
to  all  operations  effected  with  pointed  and  sharp-edged  instruments 
introduced  within  the  uterus.  From  the  statistics  of  the  previous 
sixteen  and  a  half  years  in  the  Maternite,"  he  showed  that  half  the 
mothers  thus  operated  upon  died,  and  that  the  shortest  of  these  opera- 
tions lasted  three  quarters  of  an  hour.  He  then  described  an  instru- 
ment he  had  invented,  which  he  termed  the  cephalotribe,  and  repre- 
sented that  with  it  he  could  crush  in  an  instant  the  base  and  parietes 
of  the  fetal  skull,  forcing  the  brain  from  the  orbits,  the  nostrils,  and 
the  mouth,  the  integuments  at  the  same  time  remaining  intact  and 
forming  a  sort  of  sac,  which  sufficed  to  prevent  the  edges  of  the  fract- 
ured bones  from  inflicting  injury  upon  the  soft  parts  of  the  mother. 
The  author  furthermore  expressed  his  conviction  that  the  cej)halotribe 
was  destined  to  abolish  and  replace  the  perforator  and  the  crotchet, 
and  that  it  could  be  employed  successfully  in  pelves  measuring  but 
two  inches  in  the  contracted  diameter. 

This  early  instrument  was  two  feet  long,  and  weighed  over  seven 

*TARXiErv,  "Diet,  de  Medceine  et  de  Chirurgie,"  art.  "  Embryotomie,"  vol.  xii,  p.  657. 
f  IIoDGE,  "On  Compression  of  the  Fetal  Head,"  "Am.  Jour,  of  Obstct.,"  May,  1875. 
X  A.  Ijaudelocquk,  "Revue  Med.,"  August,  1829,  p.  321. 


384 


OBSTETRIC  SURGERY. 


pounds.  In  shape  it  resembled  the  forceps.  To  the  handles  a  crank 
was  attached,  destined  to  approximate  the  enormous  blades  to  one 
another.  The  original  cephalotribe  has  since  been  subjected  to  vari- 
ous modifications,  with  a  view  chiefly  to  the  removal  of  its  repulsive 
appearance.  The  observation  of  Chailly,  in  his  '^Traite  pratique  des 
accouchements/'  1842,  that  perforation  should  always  precede  cepha- 
lotripsy,  led  specially  to  the  construction  of  lighter  and  more  conven- 
ient instruments.  The  dream  of  Baudelocque,  that  the  cephalotribe 
was  destined  to  abolish  the  perforator,  has  never  been  fulfilled. 

The  models  in  use  at  the  present  day  vary  considerably  in  weight, 
the  extent  of  the  pelvic  and  cranial  curves,  and  the  character  of  the 
apparatus  for  producing  compression.  These  different  varieties  are 
simply  expressions  of  the  defective  working  of  the  instrument  itself. 
The  shape  of  the  blades  possesses  the  greatest  importance  practically. 
It  is  to  be  borne  in  mind  that  the  cephalotribe  is  designed  to  act  both 
as  a  crusher  and  as  a  tractor.  Now,  it  so  happens  that  whatsoever 
tends  to  make  it  available  in  the  one  direction  is  obtainable  only  by 
the  sacrifice  of  some  corresponding  advantage  in  the  other.  Thus,  it  is 
evident  that  the  greatest  amount  of  crushing  force  is  exercised  when 
the  blades  run  nearly  parallel  to  one  another  ;  but,  without  a  cranial 
curve,  the  blades,  in  place  of  being  applied  to  the  convexity  of  the 
child's  head,  open  like  scissors,  and  thus  are  liable  to  slip,  if  the  in- 
strument is  employed  as  a  tractor.  Again,  as  the  blades  are  usually 
applied  in  the  transverse  or  in  an  oblique  diameter,  it  is  necessary  to 
rotate  the  cephalotribe  to  make  the  flattened  head  correspond  to  the 
flattened  pelvic  diameter.  Eotation  of  the  cephalotribe  within  the 
genital  organs  necessitates  an  instrument  without  pelvic  curve ;  and 
yet,  where  there  is  any  considerable  projection  of  the  promontory,  a 
straight  instrument  is  apt  to  seize  the  head  upon  its  posterior  aspect 
only,  and  thus  the  head  is  often  forced  from  the  blades,  when  com- 
pression is  used,  like  a  cherry-pit,  to  use  Cazeaux's  simile,  from  be- 
tween the  fingers. 


Fig.  181.— Cephalotribe  of  Blot. 


Fig.  181  represents  the  French  instrument  of  Blot,  which  is  pro- 
vided with  a  good  pelvic  curve,  but  tlie  blades  are  in  close  approxima- 


CRANIOTOMY  AND  EMBRYOTOMY.  385 

tion  to  one  another.  In  Scanzoni's  cephalotribe,  Fig.  182,  the  line  of 
greatest  difference  between  the  outer  surfaces  of  the  blades  is  nearly 
two  inches.    The  inner  surface  of  the  blades  is  supplied  with  a  longi- 


FiG.  182. — Cephalotribe  of  Scanzoni. 


tudinal  ridge  occupying  the  center,  while  the  square  extremities  curve 
sharply  inward  like  pincers.  The  instrument  possesses  a  pelvic  curve 
of  two  and  three  quarters  inches.  When  the  Scanzoni  cephalotribe  is 
applied  to  the  sides  of  the  decerebrated  head,  the  latter  lengthens  in 
the  axis  of  the  instrument,  but  Munde  reports  that  he  has  witnessed 
the  failure  of  the  instrument  to  seize  the  head  securely  in  the  Wurz- 
burg  clinic,  in  three  cases  out  of  four.  Fig.  183  represents  a  cephalo- 
tribe made  for  me  some  years  ago  by  Messrs.  Tiemann  &  Co.,  which 
has  met  with  considerable  favor  in  New  York  and  its  vicinity.  It  has 
a  cephalic  curve  of  two  inches  and  a  quarter,  measuring  from  the 
outer  surfaces  of  the  blades.*    The  pelvic  curve  is  three  inches  and 


Fig.  183.— The  author's  cephalotribe. 


two  lines  in  extent.  These  measurements  are  similar  to  those  of  the 
Prague  instruments  of  Seyfert  and  Breisky.  The  blades  are  fenes- 
trated and  grooved  upon  the  inner  surfaces.  The  advantages  of  an  in- 
strument thus  modeled  are  obvious.  It  is  possible  with  its  aid  to  seize 
the  head  when  movable  above  the  pelvic  brim.  As  the  points  ap- 
proach each  other  closely  after  compression  of  the  head  is  completed, 

*  The  advantages  of  making  the  blades  parallel  to  one  another  are  rather  apparent 
than  real ;  for,  however  effectively  compression  with  such  an  instrument  may  be  applied, 
the  head  acts  as  a  wedge,  producing  a  separation  at  the  extremities  proportioned  to  the 
absence  of  the  cephalic  curve.  Breisky  and  Seyfert  have  insisted  that  it  is  better  to 
transfer  the  greatest  width  between  the  blades  from  the  extremities  to  the  points  at  which, 
they  come  into  immediate  contact  with  the  child's  head. 
25 


386 


OBSTETRIC  SURGERY. 


the  instrument  becomes  a  perfect  tractor,  holding  the  head  as  securely 
as  an  ordinary  forceps.  Its  construction  is,  however,  virtually  the 
abandonment  of  two  favorite  but  chimerical  ideas  regarding  the  ca- 
pacity and  mode  of  action  of  the  cephalotribe,  viz.,  that  it  is  capable 
of  jSattening  the  head  so  that  the  latter  can  be  drawn  through  a  pelvis 
measuring  but  two  inches  in  the  conjugate  diameter,  and  that  this 
can  be  accomplished  by  rotating  the  instrument,  as  we  have  men-  ' 
tioned,  so  as  to  make  the  flattened  head  correspond  to  the  shortened 
diameter  of  the  pelvis. 

The  actual  result  of  compression  by  means  of  the  cephalotribe  was  long  a 
matter  of  dispute.  Baudelocque,  with  his  ponderous  instrument,  claimed  to 
have  been  able  to  instantly  crush  the  skull,  including  the  base.  Kihan  *  relates 
that  in  his  first  case  of  cephalotripsy  he  succeeded  in  breaking  up  the  skull  by 
a  single  application  into  fifty-four  pieces.  Von  Weber,  however,  made  a  large 
number  of  experiments  upon  still-born  children,  employing  for  purposes  of  com- 
parison instruments  of  various  patterns,  and  found  that  in  no  case  did  he  suc- 
ceed in  fracturing  the  bones  of  the  skull.  Even  after  the  complete  evacuation 
of  the  cerebral  contents  the  bones  would  bend,  but  did  not  fracture.  The  result 
was  different,  however,  in  cases  where  the  cephalotribe  was  employed  in  actual 
labor,  where  the  head  was  subjected  at  the  same  time  to  pressure  from  the  ute- 
rine and  pelvic  walls.  Under  such  circumstances  the  bones  certainly  may  break, 
if  they  do  not  invariably.  Fractures  he  found,  in  fact,  less  common  than  simple 
incurvations.  "Where  a  fracture  took  place  in  one  bone  it  rarely  extended  to 
contiguous  ones,  and,  in  general,  contributed  but  little  toward  the  actual  reduc- 
tion of  the  head.  Winckelt  presented  three  heads  to  the  Obstetrical  Society  of 
Berlin,  upon  which  the  cephalotribe  had  been  used  to  facilitate  delivery.  Com- 
pression, in  these  cases,  had  been  employed  in  several  diameters,  and  each  time 
the  cracking  sound  elicited  could  have  led  one  to  suppose  that  the  bones  w^ere 
being  reduced  to  small  pieces,  yet  subsequent  examination  showed  that  only  a 
single  bone,  and  that,  usually,  according  to  the  position  of  the  head,  a  parietal 
bone,  was  broken  to  any  extent,  while  the  opposite  side,  generally  the  basis 
cranii,  was  but  slightly  ruptured.  Now,  the  greatest  amount  of  compression 
effected  by  the  cephalotribe  does  not  exceed  two  to  two  and  a  quarter  inches. 
The  bizygomatic  diameter,  indeed,  which  measures  tliree  inches,  is  not,  in  or- 
dinary cephalotripsy,  attacked  at  all.  J 

It  has  always  been  objected  to  the  cephalotribe  that  its  application  in  the 
transverse  diameter  increases  the  length  of  the  head  in  the  antero-posterior 
diameter,  or  precisely  where  the  pelvis  is  the  narrowest,  and  thus  adds  to  the 
difficulty  of  delivery.  This  is  no  doubt  true  when  the  head  is  fixed  in  the  pelvis, 
a  fact  which  should  lead  us  to  give  the  preference  to  other  instruments  for  ex- 
traction after  engagement  has  taken  place.  Above  the  brim,  the  cephalotribe 
seizes  the  head  usually  in  an  oblique  diameter,  so  that  the  compensation  takes 
place  in  the  opposite  oblique  diameter.  If  the  head  is  seized  in  the  transverse 
diameter,  it  may  easily  be  rotated  into  an  oblique  diameter.    Sometimes  tlie 

*  KiLiAN,  "  Orccan  f.  die  gcsammt.  Medecin,"  Bd.  ii,  p.  279. 
f  WiNCKKL,  "  Kephalotripsie,"  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxi,  p.  81. 
X  Fritsch,  "  Der  Kcphalothryptor  und  Braun's  Cranioclast,"  Volkmann's  "  Samml. 
klin.  Vortr.,"  No.  12V,  p.  870. 


CRANIOTOMY  AND  EMBRYOTOMY. 


387 


compressed  head  rotates  spontaneously,  so  that  the  cephalotribe  comes  to  occupy 
the  conjugate,  a  thing  obviously  possible  only  in  moderate  degrees  of  contrac- 
tion. Artificial  rotation  of  the  cephalotribe  into  the  conjugate  is  dangerous  and 
should  under  no  circumstances  be  attempted.  It  must  be  borne  in  mind  that 
the  axis  of  the  instrument  is  in  a  line  between  the  upper  border  of  one  blade 
and  the  lower  border  of  the  other,  and  not  in  one  drawn  transversely  between 
them.  If  spontaneous  rotation  occurs,  the  instrument  should  be  removed,  and 
the  cranioclast  employed  as  a  tractor.  Extraction  with  a  powerful  instrument 
like  the  cephalotribe  can  not  be  safely  undertaken  when  the  points  of  pressure 
from  the  blades  are  the  soft  tissues  between  the  symphysis  and  promontory. 

Thus  we  find  the  cephalotribe  useful  in  compressing  the  head 
before  it  becomes  fixed  at  the  brim.  It  is,  moreover,  advantageous 
as  a  tractor  in  moderate  degrees  of  pelvic  contraction.  AVith  two  and 
three  quarters  inches  in  the  conjugate,  the  limit  for  its  safe  employ- 
ment is,  as  a  rule,  reached.  Of  course  it  is  understood  that  other 
factors  than  the  pelvic  diameters  may  influence  the  result.  Thus, 
much  depends  upon  the  size  of  the  child's  head,  the  resiliency  of  the 
cranial  bones,  and  the  relations  of  the  pelvic  diameters  to  one  another. 
It  is  not  disputed  that  the  cephalotribe  is  capable,  if  force  is  used,  of 
accomplishing  delivery  through  a  smaller  space  than  the  one  given, 
but  the  severe  injuries  to  the  maternal  tissues  which  the  instrument  is 
apt  to  inflict,  even  when  every  caution  is  exercised,  make  its  employ- 
ment dangerous  in  the  higher  degrees  of  pelvic  deformity. 

In  1863  Pajot*  published  a  paper  in  which  he  stated  that,  while  in  cases  of 
distortion,  in  which  the  narrowing  did  not  exceed  two  and  a  half  inches,  cepha- 
lotripsy  was  a  favorable  operation,  requiring  the  exercise  of  no  great  amount  of 
force,  and  but  two  or  three  applications  of  the  instrument,  below  that  point  he 
regarded  it  as  nearly  as  dangerous  as  the  Csesarean  section.  In  the  belief  that 
these  results  were  due  to  rude  attempts  to  drag  an  imperfectly  reduced  head 
through  the  contracted  space,  he  proposed  that  in  all  cases  below  two  and  a  half 
inches  no  tractions  should  be  made,  but,  so  soon  as  dilatation  had  proceeded  far 
enough  to  permit,  perforation  should  be  performed,  whereupon  complete  dilata- 
tion would  occur  more  speedily,  and  cephalotripsy  might  be  begun  at  an  early 
I)eriod  of  labor— a  point  in  itself  of  considerable  importance.  While  applying  the 
cephalotribe,  one  or  two  assistants  should  make  counter-pressure  over  the  pubes 
to  steady  the  head.  The  blades  should  be  introduced  as  high  as  possible  by  de- 
pressing the  handles.  After  compressing  the  head,  rotation,  if  it  has  not  occurred 
spontaneously,  should  be  cautiously  attempted.  The  slightest  obstacle  should, 
however,  be  the  signal  for  suspending  rotation  and  withdrawing  the  instrument, 
when  Nature  usually  brings  about  rotation  with  astonishing  rapidity.  The 
instrument  should  then  be  reapplied,  and  the  compression  repeated.  The  same 
process  should  be  gone  through  with  a  third  time,  after  which  the  woman 
should  be  placed  in  a  convenient  posture,  and  given  bouillon  to  drink.  Then, 
governed  by  the  state  of  the  pulse  and  the  general  appearance  of  the  patient, 
the  quiet  or  excitement  manifested,  the  weak  or  energetic  character  of  the  pains, 
the  cephalotribe  should  be  applied  two  or  three  times  every  two,  three,  or  four 

*  Pajot,  "De  la  cephalotripsie  rep6tee  sans  tractions,"  Paris,  1863. 


888 


OBSTETRIC  SURGERY. 


hours,  leaving  the  expulsion  of  the  foetus  entirely  to  Nature.  M.  Pajot  has  never 
found  more  than  four  applications  of  this  procedure  necessary,  while  one  or  two 
have  generally  sufficed.  After  the  passage  of  the  head,  one  or  two  applications 
of  the  instrument  are  required,  as  a  rule,  to  reduce  the  thorax.  To  be  success- 
ful, however,  it  is  requisite  that  the  operation  should  be  resorted  to  at  an  early 
period  of  labor,  when,  as  a  rule,  not  more  than  six  to  eighteen  hours  are  needed 
for  Nature  to  expel  the  uterine  contents.  Tractions  should  be  employed  only 
in  those  cases  to  which  one  is  called  at  a  late  period,  after  the  powers  of  Nature 
are  exhausted.  Objections  to  this  plan  of  Pajot  have  been  made  as  follows : 
That  there  is  risk  of  rupture  of  the  uterus  from  the  prolongation  of  the  labor; 
that  the  uterus  is  exposed  to  injury  from  the  spiculse  at  the  point  of  perforation  ; 
that,  owing  to  the  great  rapidity  with  which  decomposition  takes  place  after 
cephalotripsy,  the  bones  of  the  skull  are  liable  to  become  denuded  of  their  cov- 
erings; and,  finally,  that  after  a  given  period  the  membranes  become  so  far 
destroyed  as  no  longer  to  protect  the  uterus  from  its  decomposing  contents. 
Pajot  replies  by  adducing  seven  cases  in  which  he  employed  his  method.  Five 
of  the  cases  were  successful,  and  two  terminated  fatally.  The  highest  degree 
of  deformity  for  which  he  operated  was  a  case  in  which  the  contracted  diam- 
eter was  something  less  than  an  inch  and  a  half.  The  patient  died  from 
ruptured  uterus,  due,  according  to  M.  Pajot,  to  attempts  made  previous  to  his 
arrival  to  perform  cephalotripsy  with  a  badly  constructed  instrument.  The 
method  of  M.  Pajot  has  never  won  the  approbation  of  the  profession,  but,  in 
the  absence  of  the  necessary  instruments  to  execute  other  preferable  manoeuvres, 
the  success  of  its  author  recommends  it  for  trial. 

The  application  of  the  ceplialotribe  does  not  differ  from  that  of 
the  forceps.  Where  perforation  has  been  performed,  spiculae  of  bone 
should  be  carefully  removed  with  the  fingers.  Confirmatory  evidence 
as  to  the  direction  of  the  head  may  be  obtained  by  exploring  the  cra- 
nial cavity  with  the  finger,  as,  in  this  way,  the  exact  position  of  the 
base  and  vault  may  be  determined.  Great  caution  should  be  exer- 
cised during  the  introduction  of  the  blades  not  to  injure  the  vaginal 
or  uterine  tissues.  It  is  not  always  easy  to  lock  the  instrument  after 
the  blades  have  been  adjusted.  The  left  blade  is  easily  placed,  but 
often  the  right  blade  is  with  difficulty  brought  forward  to  the  cor- 
responding transverse  or  oblique  diameter.  Compression  should  be 
made  slowly,  and  the  opening  made  by  the  perforator  should  be  care- 
fully guarded  lest  cutting  portions  of  bone  protrude.  Extraction 
:  should  take  place  under  the  guidance  and  protection  of  the  fingers  of 
the  left  hand. 

Sometimes  the  ceplialotribe  is  used  to  compress  and  extract  the 
after-coming  head  in  cases  of  moderate  pelvic  contraction.  Under 
such  circumstances  perforation  is  usually  not  a  prerequisite.  The 
cephalotribe  seizes  the  head  securely,  and  acts  with  great  power  upon 
the  basis  cranii.  The  increased  diameters  of  the  head  accommodate 
themselves  more  readily,  too,  to  the  long  diameters  of  the  pelvis  than 
in  cranial  presentations.  AVhcn  the  head  is  retained  in  the  uterus 
after  it  has  become  detached  from  the  body,  it  should  be  held  by  an 


CRANIOTOMY  AND  EMBRYOTOMY. 


389 


assistant  through  the  abdominal  walls,  and  steadied  by  a  crotchet 
introduced  into  the  foramen  magnum,  or  fixed  into  an  orbit,  or  in  the 
lower  jaw\  The  cephalotribe  may  then  be 
applied  to  complete  the  extraction. 

Cranioclast. — It  is  necessary  to  distin- 
guish between  two  instruments,  each  of 
which  bears  the  name  of  cranioclast.  The 
original  model  was  the  device  of  Sir  J.  Y. 
Simpson,  and  was  intended  by  him  to 
replace  the  cephalotribe.  It  is  substan- 
tially a  powerful  pair  of  craniotomy-for- 
ceps.  The  larger  blade,  which  is  intended 
to  be  placed  upon  the  outer  surface  of  the 
head,  is  fenestrated  and  grooved.  The 
smaller  one,  for  introduction  into  the  per- 
forated skull,  is  solid  and  supplied  with 
ridges  wiiich  fit  into  the  grooves  upon 
the  opposite  blade.  The  two  blades  artic- 
ulate by  means  of  a  button-lock.  By  a 
twisting  movement,  the  cranioclast,  when 
applied,  can  be  employed  to  wrench  off  the 
bones  of  the  calvarium,  different  portions 
of  the  skull  being  seized  successively  with 
the  view  of  accomplishing  that  result.  As 
the  fractured  bones  are  covered  by  the 
scalp,  they  are  prevented  from  inflicting 
injury  during  the  subsequent  course  of  de- 
livery. But  the  cranioclast  is  not  only  of 
use  in  breaking  up  the  cranial  vault,  it  is 
likewise  the  most  effective  of  all  the  in- 
struments employed  for  extraction  of  the 
perforated  head. 

The  principal  defect  of  the  Simjoson 

cranioclast  is  that  it  attempts  to  combine     Fig.  184.— Simpson's  cranioclast. 

in  the  same  instrument  the  functions  of 

crusher  and  tractor.  Now,  as  in  the  cephalotribe,  the  devices  which 
make  it  tlie  most  effective  instrument  in  the  one  direction  weaken 
its  utility  in  the  other.  Braun's  modified  cranioclast  is  intended  to 
serve  purely  as  a  tractor.  All  idea  of  its  undertaking  to  break  up  the 
skull  is  discarded.  The  work  of  compression  and  disarticulation  is 
left  to  the  counter-pressure  of  the  pelvic  walls,  and  to  the  employ- 
ment of  craniotomy-forceps  and  the  cephalotribe.  The  term  crani- 
oclast  is  therefore  a  misnomer.  Munde^s  proposed  substitute  of  **cra- 
niotractor "  is  descriptive  of  its  real  action.  Yet  the  modifications 
of  Braun  were  as  simple  as  they  have  proved  appropriate.    A  pelvic 


390 


OBSTETRIC  SURGERY. 


curve  has  been  given  to  the  blades  ;  the  handles  have  been  lengthened 
so  that  the  lock,  even  when  the  instrument  is  introduced  high  up,  is 


Fig.  185. — Braun's  cranioclast. 


outside  the  vulva  ;  and,  finally,  an  apparatus  for  compression  has  been 
added.  The  advantages  of  Braun's  cranioclast  over  its  rival,  the 
cephalotribe,  are  as  follows  :  it  is  of  comparatively  small  size  ;  again, 
one  branch  lies  inside  tlie  head,  in  a  space  not  otherwise  occupied  ; 
the  outer  branch  imbeds  itself  in  the  soft  coverings  of  the  head, 


i  V 

f 

1 1 

u 

1 

\  fe^ 

J— 

Fig.  186.— Head  of  child  after  delivery  with  the  cranioclast.  (Simpson.) 

and  thus  is  protected  from  doing  harm.  After  a  few  tractions  the 
cranioclast  occupies  the  middle  of  the  pelvis,  where  it  can  be  so 
guarded  by  the  hand  that  it  need  not  even  come  into  contact  with  the 


CRANIOTOMY  AND  EMBRYOTOMY. 


391 


vaginal  walls  ;  as  the  head  is  drawn  into  the  pelvis,  the  pressure  is  not 
concentrated  at  one  or  two  points,  but  is  diffused  over  the  entire  ]3elvic 
rim ;  the  head  is  therefore  able  to  mold  itself  to  the  shape  of  the 
pelvis.  Subsequent  to  the  use  of  Braun's  cranioclast,  extensive  lacera- 
tions and  injuries  to  the  maternal  organs  are  rarely  found.  The  cra- 
nioclast  takes  firm  hold  of  the  head.  It  never  slips  during  extraction. 
It  is  not  apt  to  tear  away  when  the  cranium  and  scalp  are  seized 
together.  The  most  secure  grip  is  obtained  when  the  inner  blade  is 
passed  to  the  base  of  the  skull,  while  the  outer  one  is  applied  to  tlie 
face  or  over  an  ear.  Should  the  portion  grasped  tear  away,  the  read- 
justment of  the  instrument  upon  another  part  of  the  skull  is  easy. 
Thus,  the  inner  blade  can  be  turned,  of  course,  in  any  direction  with- 
out difficulty,  while  the  outer  blade  is  easily  disengaged  from  the  scalp- 
tissues  and  changed  in  its  position  by  direct  pressure  from  the  fingers 
and  slight  leverage  movements  of  the  handle. 

The  cranioclast  may  often  advantageously  be  used  as  a  tractor  in 
cases  where  the  head  has  been  previously  crushed  and  flattened  by  the 
cephalotribe,  but,  where  extraction  with  the  latter  is  rendered  difficult 
by  slipping,  or  by  the  inability  of  the  operator  to  make  the  altered 
diameters  of  the  head  correspond  to  those  of  the  contracted  pelvic 
space,  the  immense  superiority  of  the  cranioclast  consists  in  the  capa- 
city to  seize  the  head  antero-posteriorly,  and  thus  to  bring  its  length- 
ened diameter  into  the  transverse  space  of  the  pelvis. 

The  cranioclast  enables  us  to  extend  the  limits  of  safe  delivery  far 
beyond  what  would  be  admissible  with  the  cephalotribe,  as  with  its  aid 
it  is  possible,  after  the  partial  or  complete  removal  of  the  flat  bones  of 
the  skull,  to  tilt  the  chin  downward,  and  draw  the  base  by  the  edge 
through  the  conjugate.  In  this  way  craniotomy  may  be  resorted  to 
in  pelves  measuring  less  than  two  and  three  fourths  inches  antero-pos- 
teriorly. Indeed,  Barnes  claims  that  one  inch  and  three  fourths  in 
the  conjugate  and  three  inches  in  the  transverse  diameter  furnish 
sufficient  space  for  a  successful  operation.  * 

The  proceeding  to  be  pursued  in  these  difficult  cases  is  as  follows  : 
After  perforation  introduce  a  forcei:)s-blade  under  the  scalp,  and  detach 
the  latter  as  far  as  possible  from  the  cranial  bones  ;  break  up  and  wash 
out  the  entire  brain-mass  ;  seize  the  parietal  bones  beneath  the  scalp 
with  a  good  pair  of  craniotomy-forceps,f  and  break  them  away  piece- 
meal by  a  twisting  movement  of  the  wrist.  The  withdrawal  of  the 
fractured  bones  is  always  a  matter  of  delicacy.    Unless  the  soft  parts 

*  Barnes,  "  Obstetric  Operations,"  p.  402.  For  discussion  of  this  point,  see  "  Treat- 
ment of  Contracted  Pelves." 

I  f  Meigs's  craniotoniy-iorceps  has  been  largely  used  in  America,  and  may  be  confi- 
l  itly  recommended.  There  are  two  forms,  one  straight  and  the  other  curved.  Dr.  Tay- 
I  's  modification  consisted  chiefly  in  increasing  the  length  of  the  instrument,  so  as  to 
\     der  it  more  available  in  operations  at  the  superior  strait. 


392 


OBSTETRIC  SURGERY. 


ar^  carefully  guarded  by  the  hand,  the  maternal  tissues  are  apt  to  be  cut 
and  lacerated  by  the  sharp  edges  and  splintered  corners  of  the  bones. 


Fig.  187. — Meigs's  craniotomy- forceps  (modified  by  Professor  1.  E.  Taylor). 


Skene*  has  found  it  a  great  aid,  in  some  cases,  to  use  a  large-sized 
Sims  speculum  to  bring  the  head  into  view,  and  to  go  through  the 
various  steps  of  craniotomy  with  the  guidance  of  the  eye.  The  sug- 
gestion is  an  excellent  one,  but  when  the  head  is  high  up,  as  is  the 
rule  in  difficult  cases,  I  have  not  always  found  it  practicable  to  expose 
in  this  way  the  presenting  part.  Horwitz  f  recommends,  in  difficult 
cases  of  the  unexpanded  cervix,  to  perforate  through  a  large  Fergusson 
speculum. 

After  the  removal  of  the  parietal  bones,  the  fenestrated  blade 
should  be  placed  under  the  chin,  or  in  the  mouth,  while  the  smaller 
one  is  introduced  inside  the  perforation,  and  applied  so  that  the  fron- 
tal bones  are  included  in  the  grasp  of  the  instrument.  The  blades 
should  then  be  screwed  tightly  together  by  means  of  the  apparatus  for 
compression,  and  the  head  turned  so  that  its  bizygomatic  diameter  is 
brought  into  the  transverse  diameter  of  the  pelvis.  As  the  distance 
between  the  orbital  plates  and  the  chin,  including  the  instrument, 
does  not  exceed  two  inches,  and  the  width  of  the  base  is  only  about 
three  inches,  it  is  evident  that,  in  skillful  and  experienced  hands,  this 
method  is  capable  of  almost  indefinite  extension. 

After  delivery  of  the  head,  the  extraction  of  the  body  may  still 
cause  difficulty.  If,  then,  through  an  opening  made  with  a  perforator 
between  the  clavicle  and  shoulder-blade,  the  smaller  blade  be  intro- 

*  Skene,  "  Trans,  of  the  Am.  Gynaec.  See,"  vol.  ii.  I 
t  IIoRwiTz,  "  Ubcjr  ein  Perforations  Verfahren,"  "  Ztschr.  f.  Geburtsh.  u.  Gynaek.,'j 
Dd.  iv,  p.  1.  I 

1  N. 

I" 


CRANIOTOMY  AND  EMBRYOTOMY. 


393 


dnced,  and  the  outer  blade  be  applied  on  the  back,  so  that  the  two 
include  the  spine,  the  cranioclast  will  seize  the  trunk  firmly,  and  is 
capable  of  exerting  great  force  as  a  tractor. 

Crotchet  and  Blunt  Hooh. — As  tractors,  neither  of  these  instru- 
ments is  much  in  vogue  at  the  present  day.  It  is  well,  however,  to 
become  familiar  with  their  uses,  as  we  are  not  always  placed  where 
we  can  have  a  complete  armamentarium  at  our  disposal. 


Fig.  188.— Crotchet. 

The  crotchet  is  a  steel  hook,  with  a  sharp-pointed  extremity.  The 
shaft  is  either  straight  or  curved  to  adapt  it  better  to  the  convexity  of 
the  head.  In  craniotomy  the  instrument  is  often  useful  in  breaking 
up  the  brain.  It  may  be  inserted  into  an  orbit  when  it  is  desired  to 
bring  the  base  of  the  skull  end  on  into  the  pelvis.  In  default  of  either 
cranioclast  or  cephalotribe,  it  may  be  employed  to  extract  the  perfo- 
rated head.  To  this  end  it  should  be  passed  through  the  opening  and 
its  point  inserted  into  one  of  the  bones  of  the  cranial  vault.  Two  fin- 
gers of  the  left  hand  are  then  passed  to  the  outer  surface  of  the  skull, 
to  serve  as  a  guard  and  to  make  pressure  against  the  point  fixed  upon 
the  inner  surface.  If  much  resistance  is  met  with,  the  part  is  apt  to 
tear  away,  and  a  new  hold  has  to  be  taken.  When  portions  of  bone  are 
broken  away,  they  should  be  removed  with  the  fingers,  to  prevent  their 
doing  harm.  The  process  is  often  tedious,  and,  in  unskillful  hands, 
is  not  devoid  of  danger.  AYhen  the  bones  of  the  vault  yield  under 
traction,  a  more  effective  grip  may  sometimes  be  obtained  by  fixing 
the  crotchet  at  the  foramen  magnum  or  the  sella  turcica.  Or,  in  place 
of  introducing  the  instrument  into  the  skull,  it  is  sometimes  inserted 
outside,  behind  the  ear,  into  the  mastoid  process,  or  into  the  occiput, 
near  the  foramen  magnum.    The  blunt  hook,  though  not  indispensa- 


FiG.  189.— Dr.  Taylor's  right-angled  blunt  hook. 


ble,  is  capable  of  rendering  valuable  service  in  delivering  the  head 
after  the  performance  of  craniotomy.  Dr.  I.  E.  Taylor  gives  the 
preference  to  a  right-angled  instrument.  The  blunt  hook  can  not,  of 
course,  be  attached  to  flat  surfaces  of  bone.    It  may  be  used,  however. 


394 


OBSTETRIC  SURGERY. 


to  draw  down  the  chin,  or  it  may  be  thrust  into  an  orbit.  Where 
perforation  has  been  made  upon  the  after-coming  head,  the  blunt  hook 
may  be  introduced  through  the  opening  and  traction  made  directly 
upon  the  base  of  the  skull.  In  difficult  cases,  delivery  of  the  trunk  is 
sometimes  favored  by  tractions  made  by  a  blunt  hook  inserted  under 
the  posterior  shoulder. 

Version. — Version,  with  extraction  by  the  feet,  with  or  without 
cephalotripsy,  has  been  warmly  commended  by  Bertin,  Tarnier,*  and 
Taylor,  f  while  it  has  been  condemned  in  harsh  terms  by  others.  Where 
it  is  practicable  to  perforate  and  turn  early  in  labor,  at  a  time  when 
version  is  easy,  the  method  has  the  advantage  of  bringing  the  longest 
diameter  of  the  head  into  correspondence  with  the  long  diameter  of 
the  pelvis,  and  favoring  the  molding  of  the  head  to  the  shape  of  the 
canal  it  has  to  traverse.  At  the  same  time  it  avoids  the  dangers  of 
contusing  the  soft  parts  incident  to  the  use  of  the  cephalotribe.  Dr. 
Taylor  recommends  combining  propulsion  above  the  pubes  with  trac- 
tions made  upon  the  extremities. 

Great  ingenuity  has  been  exerted  to  devise  some  good  way  to  overcome  the 
dilRculty  which  grows  out  of  the  defectiveness  of  the  preceding  measures  in  act- 
ing directly  upon  the  base  of  the  skull.    Cephalotoray,!  or  the  removal  of  the 
liead  by  segments,  has  been  proposed  as  a  substitute  for 
perforation  and  cephalotripsy.    Van  Huevel's  forceps-saw 
divides  the  head  from  crown  to  base  into  two  halves. 
Tarnier's  forceps-saw  removes  from  the  head  a  triangular 
segment,  the  apex  of  which  is  cut  from  the  skull -base. 
Dr.  Barnes*  has  suggested  the  application  of  Braxton 
Hicks's  wire  ecraseur  to  successive  portions  of  the  head. 
Hubert's  transforateur  is  designed  to  bore  through  the 
sphenoid,  and  thus  to  destroy  the  resistance  of  the  base. 
The  sphenotribes  of  Valette,  Htiter,  and  the  Lollines,  are  a 
combination  of  the  cephalotribe  and  the  transforateur. 
Notwithstanding  the  principle  of  cephalotomy  is  mechani- 
cally correct,  the  operation  has  never  met  with  any  general 
acceptance,  partly  owing  to  the  high  price  and  compli- 
cated structure  of  most  of  the  instruments  required  for  its 
Fig.  190.— Segment  re-  performance,  and  perhaps  in  part  to  the  fact  that,  in  the 
moved  by  tlie  Tar-  higher  degrees  of  pelvic  deformity  where  their  advantages 
(P.  Thomas.)  *    "   over  the  more  familiar  methods  would  be  theoretically 
mof^t  complete,  the  bulky  nature  of  the  forceps-saws  and 
the  sphenotribes  interferes  with  their  employment.    The  favorable  reports  made 
by  their  inventors,  of  the  results  they  have  personally  obtained,  render,  however, 
a  reference  to  the  subject  necessary. 

*  Tarnieu,  "  Diet,  de  Medccinc  ct  de  Chirurgie.,"  art.  "  Embryotomie,"  t.  xii,  p.  668. 
f  Taylor,  "  What  is  the  Best  Treatment  in  Contracted  Pelves  ?  "  "  Trans,  of  the  New 

York  Acad,  of  Med.,"  1875. 

X  Tarnier,  *'  Diet,  de  Medccinc  et  de  Chirurgie,"  art.  "  Embryotomie,"  p.  680. 

*  Barnes,  "Obstetric  Operations,"  p.  411. 


CRANIOTOMY  AND  EMBRYOTOMY. 


395 


Embryotomy. 

In  a  literal  sense,  embryotomy  includes  all  the  graver  operations 
designed  to  diminish  the  volume  and  resistance  of  the  foetus.  Custom 
has,  however,  restricted  the  term  to  those  operations  only  which  are 
performed  upon  the  trunk  of  the  child.  It  is  used,  therefore,  as  a 
rule,  in  contradistinction  to  craniotomy,  and  not  in  its  generic  sense. 

Indications  for  Embryotomy. — 1.  In  extreme  degrees  of  pelvic  con- 
traction, where  the  size  of  the  body  obstructs  delivery.*  2.  In  fetal 
malformations,  with  abdominal  enlargement  due  to  pathological  con- 
ditions of  the  more  important  viscera,  and  in  cases  of  extraordinarily 
developed  children.  3.  In  neglected  transverse  presentations,  in  which 
version  is  impossible,  or,  at  least,  can  not  be  performed  without  en- 
dangering greatly  the  life  of  the  mother. 

Embryotomy  includes  two  operative  measures,  viz.,  exenteration 
and  decapitation. 

Exenteration. — By  exenteration  we  mean  the  opening  of  one  of  the 
large  cavities  of  the  trunk,  and  the  removal  of  the  contained  viscera. 
It  is  most  commonly  indicated  in  transverse  presentations,  where  de- 
capitation is  not  easy  to  perform,  as  in  cases  of  extreme  pelvic  con- 
traction with  the  head  high  up  above  the  pelvis.  The  opening  may  be 
made  by  means  of  a  pair  of  curved  scissors  or  the  ordinary  perforator. 
The  same  precautions  against  injury  of  the  maternal  tissues  have  to 
be  observed  as  in  craniotomy.  In  shoulder  presentations  an  assistant 
should  press  the  fundus  of  the  uterus  downward.  The  operator  at  the 
same  time  thrusts  the  perforator,  or  the  scissors,  between  the  ribs,  and 
then  enlarges  the  opening  by  turning  the  instrument  so  as  to  make  a 
second  incision  at  right  angles  to  the  first.  Next,  splintered  portions 
of  bone  should  be  carefully  broken  away  with  the  fingers,  until  the 
opening  becomes  sufficiently  extensive  to  permit  the  introduction  of 
the  half -hand.  In  tearing  away  the  viscera,  the  fingers  may,  if  neces- 
sary, be  aided  by  the  volsella-forceps.  The  abdominal  cavity  may 
be  reached  directly  through  the  thorax  by  perforation  of  the  dia- 
phragm, or  a  fresh  opening  may  be  made  through  the  abdominal  walls. 

After  evisceration,  the  reduced  bulk  of  the  child  renders  it  pos- 
sible to  proceed  directly  to  seize  the  feet  and  perform  version.  This 
method  is,  however,  generally  difficult,  and  endangers  the  distended 
cervix  and  lower  uterine  segment.  If,  therefore,  the  shoulder  is  high 
up,  the  breech,  which  is  easily  reached,  should  be  drawn  down  with 

*  It  has  been  said  that,  in  cases  which  do  not  demand  the  Caesarean  section,  this  indi- 
cation is  not  likely  to  arise.  In  the  extraction  of  the  child's  body,  however,  through  a 
small  justo-minor  pelvis,  which  required  for  its  completion  upAvard  of  twenty -five  min- 
utes, ^'>os^-mor/em  examination  showed  more  extensive  disturbances  from  arrested  pelvic 
circulation,  due  to  compression  from  the  child's  body,  than  from  the  lesions  arising  out 
of  the  performance  of  craniotomy. 


OBSTETRIC  SURGERY. 


396 


the  fingers  or  the  blunt  hook,  in  imitation  cf  the  mode  of  delivery  in 
spontaneous  version.  When,  however,  an  arm  presents,  and  the  shoul- 


FiG.  191. — Braun's  decapitating  hook. 


der  is  crowded  into  the  pelvis,  the  child  may  be  drawn  through  doubled 
upon  itself,  as  in  spontaneous  evolution. 

Decapitation. — Whenever,  in  neglected  transverse  presentations,  the 

neck  can  be  easily 
reached,  decapitation 
furnishes  the  simplest 
and  mildest  plan  for 
overcoming  the  diffi- 
culties which  prevent 
delivery. 

Decapitation  may 
be  effected  in  a  num- 
ber of  different  ways  : 

1.  Draw  upon  the 
prolapsed  arm  to  bring 
the  neck  well  down, 
and  within  reach.  Pass 
the  finger  or  a  blunt 
hook  around  the  neck, 
and  then,  carefully 
guarding  the  points, 
divide  with  a  strong 
pair  of  scissors  by  a 
series  of  short  move- 
ments the  soft  struct- 
ures and  the  vertebral 
column. 

2.  In  many  cases 
the  division  of  the 
neck  can  be  advanta- 
geously accomplished 
by  Braun's  decollator. 

This  instrument  is  a  modification  of  the  blunt  hook.    The  terminal 


Fio.  192 


method  of  decapitation. 


CRANIOTOMY  AND  EMBRYOTOMY. 


397 


portion  is,  howeyer,  bent  at  nearly  an  acute  angle.  It  is  likewise 
flattened  from  side  to  side,  and  ends  in  a  button-shaped  extremity. 
The  handle  is  fixed  at  a  right  angle,  and  is  capable  of  imparting  to 
the  instrument  powerful  leverage  movements.  In  employing  the  de- 
collator, the  index  and  middle  fingers  of  the  left  hand  should  encir- 
cle the  child's  neck  from  behind,  while  the  thumb  is  placed  upon  the 
anterior  surface.  The  neck  should  then  be  firmly  grasped  and  drawn 
down  into  the  pelvis  as  far  as  possible.  The  decollator  should  be 
passed  up  flat  under  the  symphysis  pubis  along  the  thumb  of  the 
operator,  until  the  button-end  has  advanced  far  enough  to  be  turned 
to  the  rear  over  the  neck.  Finally,  the  instrument  should  be  seized 
by  the  handle  with  the  right  hand,  and  rotated  to  and  fro,  while 
tractions  are  simultaneously  made  in  a  downward  direction.  It  is 
surprising  how  quickly,  as  a  rule,  the  spinal  column  may  be  divided 
by  this  manoeuvre.  After  the  separation  of  the  vertebrae,  care  must  be 
taken  not  to  draw  down  with  too  much  force,  lest  the  integuments  and 
soft  structures  yield  suddenly,  and  violence  be  done  by  the  rapid  with- 
drawal of  the  instrument.  This  accident  may  be  avoided  by  using 
moderate  tractions  and  dividing  the  last  remnant  of  the  tissues  with  a 
pair  of  scissors.  The  decapitating  hook  of  Ramsbotham,  which  is 
curved,  and  has  a  cutting  edge  upon  the  concave  part,  is  more  difficult 
to  apply,  and  is  a  less  safe  instrument  in  unskillful  hands. 


Fig.  193.— Embryotome  of  P.  Tliomas. 


3.  Pajot  originated  an  ingenious  method  of  decapitation,  which,  in 
default  of  special  instruments,  is  capable  of  rendering  valuable  service. 
It  consists  in  passing  a  strong  cord  around  the  child's  neck,  and,  by  a 


398 


OBSTETRIC  SURGERY. 


sawing  movement,  cutting  tlirongh  the  parts.  The  vagina  should  be 
protected  by  a  specuhim  from  the  friction  produced  by  the  to-and-fro 
movement  of  the  string.  The  chief  difficulty  of  the  operation  lies  in 
getting  the  string  around  the  neck.  Pajot  caused  a  groove  to  be  made 
upon  the  concave  surface  of  the  blunt  hook  which  forms  a  constant 
attachment  to  one  of  the  handles  of  the  ordinary  French  forceps. 
Through  this  groove  he  passes  a  string,  to  the  end  of  which  he  fastens 

a  round  lead  bullet ;  when 
the  blunt  hook  is  adjusted 
about  the  child's  neck,  the 
weight  of  the  bullet  draws 
the  cord  downward  so  that 
it  can  be  reached  by  the 
hand  of  the  operator.  Dr. 
Kidd  recommends  attach- 
ing a  string  to  an  elastic  ca- 
theter armed  with  a  strong 
stylet ;  then,  after  impart- 
ing to  the  instrument  the 
proper  curve,  it  should  be 
passed  around  the  child's 
neck,  and,  as  it  is  with- 
drawn, the  string  should  be 
used  to  drag  a  strong  cord 
or  the  chain  ecraseur  into 
place. 

Still  more  ingenious  is 
the  embryotome  of  Pierre 
Thomas,  consisting  of  two 
blades  modeled  after  a 
somewhat  expensive  instru- 
ment devised  by  M.  Tar- 
nier.  The  curved  blade 
should  be  passed  posterior- 
ly opposite  the  sacrum.  The 
straight  blade  should  be 
introduced  in  front  direct- 
ly beneath  the  pubic  bones. 
When  adjusted,  the  extrem- 
ities of  the  blades  are  in 
apposition.  Both  blades  contain  a  grooved  canal.  A  piece  of  whale- 
bone armed  with  an  ivory  knob  is  then  introduced  into  the  canal  of 
the  straight  blade,  while  a  long,  flexible  piece  of  whalebone  provided 
with  an  ivory  ring  is  passed  into  the  canal  of  the  posterior  curved 
blade.    The  descent  of  the  posterior  whalebone  furnishes  the  evidence 


Fig 


194. — Embryotome  adjusted  around  the  neck  of 
the  child. 


CJESAREAX  SECTIOX.— OPERATIONS  OF  THOMAS  AND  PORRO.  399 

that  tlie  canals  of  tlie  two  blades  are  in  apposition,  and  that  the  longer 
piece  has  entered  the  posterior  canal.  When  the  circuit  is  completed, 
a  loop  of  cord  is  passed  through  an  eyelet  in  the  end  of  the  whalebone, 
and  serves  as  an  attachment  to  a  chain-saw,  which,  as  it  is  drawn 
upward,  leaves  the  groove  and  encircles  the  child's  neck.  In  decapi- 
tating the  child  by  a  to-and-fro  movement,  the  soft  parts  are  protected 
by  the  blades  of  the  embryotome. 


CHAPTER  XXIIL 

CESAREAN  SECTIOK—OPEEATIOKS  OF  THOMAS  AND  POERO. 

Caesarean  section. — History. — Indications. — Operation. — After  -  treatment. — Prognosis. — 
Operation  of  Porro. — Operation  of  Thomas. 

The  Cesarean  Sectioi^. 

The  term  Cmsarean  section  is  applied  to  cases  in  which  the  foetus 
is  removed  from  the  mother  by  an  incision  made  through  the  abdomi- 
nal and  uterine  walls. 

Although  the  operation  pretends  to  great  antiquity,  the  earlier  his- 
tories are  probably  of  mythical  origin.  The  supposed  references  in 
the  Talmud  are,  according  to  Rodenstein,  mistranslations  of  the 
text.  The  same  authority  suggests  that  even  the  lex  regis,  attrib- 
uted to  Numa  Pompilius,  which  makes  it  obligatory  upon  the  physi- 
cian to  remove  the  child  by  abdominal  section  in  case  the  mother  dies 
during  pregnancy,  was  really  added  to  the  Roman  law  in  the  middle 
ages,  v/ith  the  intention  of  giving  force  to  the  decretals  of  the  Church, 
which  sought,  through  the  Caesarean  section  upon  the  dead,  to  rescue 
the  child  for  the  rite  of  baptism  before  its  life  became  extinct.  Dur- 
ing the  sixteenth  century  there  seems  no  reason  to  doubt  the  authen- 
ticity of  certain  cases  of  laparotomy,  performed  during  the  life  of  the 
mother,  for  the  removal  of  the  foetus  in  extra-uterine  pregnancies.  In 
1581  rran9oi3  Rousset  *  published  the  histories  of  fourteen  successful 
Caesarean  sections,  six  of  which  were  said  to  have  been  performed  upon 
the  same  individual.  These  cases  were  repeated  from  hearsay,  and 
from  accounts  taken  from  letters  written  by  friends.  Their  genuine- 
ness was  challenged  at  the  time  of  publication  by  the  opponents  of  the 
operation,  and  they  are  now  generally  regarded  as  resting  upon  ques- 
tionable authority.  The  first  operations  mentioned  after  the  publica- 
tion of  Rousset's  work  are  said  to  have  proved  fatal.  The  earliest  well- 
authenticated  record  of  Caesarean  section  comes  to  us  from  Germany. 
It  was  performed  in  Wittenberg,  by  Trautmann,  in  1610.    The  patient 

*  Rousset,  "  Traite  nouvcau  do  I'hystcrotomotokie,  ou  enfantement  Cesarienne." 


400 


OBSTETRIC  SURGERY. 


lived  from  the  21st  of  April  to  tlie  16tli  of  May.  Scarcely  any  doubt 
was  entertained  of  lier  recovery,  Avlien  she  Avas  suddenly  seized  with  a 
fainting-fit  and  died,  contrary  to  all  ex]3ectation,  in  about  half  an  hour. 

Indications  for  the  Cesarean  Section. — As  the  Caesarean  section  be- 
longs to  the  most  hazardous  operations  of  surgery,  its  performance  is 
chiefly  justifiable  in  cases  in  which  craniotomy  and  the  delivery  of  the 
child  by  the  natural  passages  involve  the  life  of  the  mother  in  still 
greater  peril.  It  is  indicated,  therefore,  in  extreme  degrees  of  pelvic 
contraction,  in  the  case  of  solid  tumors  which  encroach  upon  the  pelvic 
space,  and  in  advanced  carcinomatous  degeneration  of  the  cervix. 

The  Caesarean  section  is  permissible  if  the  mother  is  moribund,  and 
the  child  is  known  to  be  alive,  where  rapid  delivery  by  the  natural 
passages  is  impossible.  It  may  be  undertaken  at  the  mother's  request 
if  otherwise  delivery  can  not  be  accomplished  without  the  sacrifice  of 
the  child.  If  in  any  case  the  decision  is  left  to  the  physician,  he 
should  regard  the  welfare  of  the  mother  as  of  paramount  importance. 
It  has  been  said  that  if  a  woman,  knowing  herself  to  be  incapable  of 
bearing  living  children,  exposes  herself  to  the  repetition  of  pregnancy, 
it  becomes  the  duty  of  the  physician  to  perform  the  Caesarean  section 
in  the  interest  of  the  child.  The  duty  of  the  physician  is,  however, 
to  his  patient.  He  is  not  to  constitute  himself  either  judge  or  exe- 
cutioner. 

Operation. — The  success  of  Caesarean  section  depends  in  large 
measure  upon  the  control  which  the  obstetric  surgeon  possesses  over 
the  conditions  under  which  the  operation  is  performed.  The  most 
suitable  time  to  operate  is  after  dilatation  has  begun,  but  previous  to 
the  rupture  of  the  membranes  :  after  dilatation,  because  it  is  desir- 
able to  provide  a  free  outlet  for  the  uterine  discharges  subsequent  to 
the  operation,  and  because  the  retraction  of  the  uterus  after  delivery, 
which  furnishes  the  most  efficient  means  of  controlling  haemorrhage 
from  the  uterine  wound,  is  best  secured  if  the  operation  is  performed 
at  a  time  when  the  contractions  are  strong  and  frequent  ;  previous  to 
rupture,  because  there  is  then  greater  probability  of  finding  the  child 
alive  and  the  maternal  tissues  uninjured.  Unless,  too,  the  head  or 
breech  protrudes  spontaneously  through  the  incision  made  in  the 
uterine  wall,  the  delivery  is  much  more  readily  performed  while  the 
membranes  are  intact  than  after  the  uterus  has  retracted  firmly  down 
upon  the  child's  body.  Michaelis  reports  a  successful  case  operated 
upon  by  Schmitt,  of  Eylau,  after  eighty  hours  labor,  and  long  after 
the  escape  of  the  waters,  where  the  incision  had  to  be  extended  over 
six  inches  in  length  before  extraction  could  be  accomplished.* 

The  room  where  the  operation  is  performed  should  be  thoroughly 
aired  and  disinfected  by  the  free  use  of  the  carbolic-acid  spray,  and 
the  temperature  raised  to  from  75°  to  80°  Fahr.    A  convenient  oper- 

*  Michaelis,  "  Abhandlungen  aiis  dcm  Gebictc  dcr  Geburtshiilfe,"  p.  162. 


CESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.  401 

ating-table  can  be  readily  improvised  by  covering  an  ironing-table  with 
blankets  or  an  old-fashioned  comforter.  The  head  of  the  patient 
should  be  moderately  elevated,  the  lower  extremities  slightly  flexed, 
and  the  knees  rotated  outward.  The  abdominal  tension  in  the  com- 
plete horizontal  position  is  apt  to  impede  the  circulation  and  respira- 
tion, and  to  facilitate  intestinal  hernia  when  the  abdominal  incision 
is  made.  Ether  should  be  employed  as  an  anaesthetic  in  preference  to 
chloroform.  All  the  details  of  antiseptic  surgery  should  be  carried 
out  with  painstaking  exactitude. 

Five  assistants  are  requisite,  viz. :  one  to  superintend  the  carbolic 
spray  ;  one  to  give  ether  ;  one  to  steady  the  uterus  and  hold  back  the 
intestines  ;  one  to  take  charge  of  the  instruments  ;  and,  finally,  a 
nurse  experienced  in  the  methods  for  resuscitating  partially  asphyxi- 
ated children,  to  receive  the  infant. 

Convenient  instruments  to  have  in  readiness  are  :  a  scalpel,  a  blunt- 
pointed  bistoury,  two  pairs  of  scissors,  one  straight,  and  the  other 
bent  at  an  angle,  a  large  grooved  director,  artery-forceps,  a  half-dozen 
pair  of  Koeberle's  compressing  forceps,  suture-needles,  a  long-handled 
needle-holder,  sponge-holders,  and  plenty  of  clean,  new  sponges, 
which  have  been  carefully  soaked  in  a  two-per-cent.  solution  of  car- 
bolic acid.  The  instruments,  with  silver  wire  for  sutures,  should  be 
kept  immersed  in  a  similar  solution  up  to  the  time  they  are  removed 
for  actual  use.  If  silk  ligatures  are  employed,  they  should  be  first 
carbolized.  A  vessel  with  warm  carbolized  water  should  be  conven- 
iently placed  where  the  operator  fi^om  time  to  time  can  bathe  his 
hands.  For  the  dressing,  subsequent  to  the  operation,  protective  silk, 
antiseptic  gauze,  borated  or  thoroughly  cleaned  cotton,  and  a  broad 
abdominal  bandage,  should  be  provided. 

The  operation  consists  of  four  stages,  viz.  :  1.  The  incision  through 
the  abdominal  wall ;  2.  The  incision  into  the  uterus  and  the  extrac- 
tion of  the  foetus  ;  3.  The  removal  of  the  placenta,  the  arrest  of 
haemorrhage,  and  the  cleansing  of  the  peritoneal  cavity  ;  4.  The  clos- 
ure and  dressing  of  the  abdominal  wound. 

1.  After  the  operator  has  passed  the  catheter,  and  personally  ascer- 
tained that  the  bladder  has  been  emptied,  he  places  himself  to  the 
right  of  his  patient.  The  assistant  stands  upon  the  opposite  side.  The 
presence  of  loops  of  intestines  in  front  of  the  uterus  is  then  care- 
fully ascertained  by  percussion.  If  intestines  are  "detected  they  should 
be  pushed  to  the  sides  of  the  uterus  out  of  harm's  way.  After  first 
washing  the  abdomen  with  carbolized  water,  the  assistant  steadies  the 
uterus  in  the  median  line,  and  produces  a  moderate  degree  of  abdom- 
inal tension  by  means  of  the  hands  so  placed  that  the  ulnar  edges 
press  against  the  sides,  and  the  thumbs  encircle  the  fundus.  The 
principal  function  of  this  assistant  is  to  guard  the  field  of  operation 
from  the  protrusion  forward  of  the  intestines.    The  entire  operation 

26 


402 


OBSTETRIC  SURGERY. 


should  be  conducted  in  an  atmosphere  of  carbolized  spray.  The  in- 
cision now  universally  adopted  is  made  through  the  linea  alba,  and 
should  extend  from  a  point  just  below  the  navel  to  a  distance  two  or 
three  fingers  in  breadth  above  the  symphysis  pubis.  In  rachitic  and 
undersized  persons,  the  length  of  this  incision  may  require  subse- 
quently to  be  increased,  in  which  case  it  should  be  extended  upward 
to  the  left  of  the  umbilicus.  The  section  through  the  abdominal  wall 
should  be  performed  deliberately,  and  layer  by  layer.  Bleeding  from 
vessels  should  be  arrested  by  compression  or  by  ligature.  When  the 
peritonaeum  is  reached,  it  should  be  raised  by  the  artery-forceps,  a 
small  opening  should  be  made,  and  the  incision  then  extended  under 
the  guidance  of  the  index  and  middle  fingers,  or  of  a  grooved  direct- 
or, the  entire  length  of  the  wound. 

2.  When  the  surface  of  the  uterus  is  exposed  to  view,  and  an  ex- 
amination has  been  instituted  to  make  sure  that  neither  omentum  nor 
intestines  present,  the  assistant  redoubles  his  vigilance.  Above  and 
at  the  sides  he  should  compress  the  uterus  firmly,  and  push  it  some- 
what forward.  He  should  keep  the  middle  of  the  uterus  carefully  in 
the  line  of  the  abdominal  incision,  and  be  in  readiness,  after  the 
opening  is  made  in  the  walls,  to  quickly  insert  his  index-fingers  into 
the  upper  and  lower  angles  of  the  wound.  The  incision  through  the 
uterine  walls  should  be  made  with  a  scalpel.  The  division  of  the 
muscular  fibers  should  take  place  layer  by  layer.  The  operator  should, 
however,  work  rapidly,  as  the  hasmorrhage,  which  is  often  enormous, 
can  only  be  controlled  by  the  removal  of  the  foetus.  The  site  of  the 
incision  should  be  as  nearly  as  possible  in  the  body  of  the  uterus. 
Both  the  fundus  and  the  parts  adjoining  the  os  internum  should, 
where  it  is  possible,  be  avoided.  The  length  of  the  incision  required 
for  the  extraction  of  the  child  should  be  at  least  four  and  a  half  to  five 
inches.  To  reduce  the  haemorrhage  to  the  smallest  limits,  it  is  a  good 
plan  to  begin  with  an  incision  of  two  inches,  and  work  down  at  the 
lower  angle  of  the  wound  to  the  membranes,  or,  where  the  amniotic 
fluid  has  escaped,  to  tlie  body  of  the  child.  Under  the  guidance  of 
one  or  two  fingers,  the  wound  may  then  be  lengthened  upward  by 
means  of  a  blunt-pointed  bistoury.  Every  care  should  be  exercised  to 
avoid  puncturing  the  ovum,  if  at  the  time  of  operating  it  happens  to 
be  still  intact.  The  moment  the  uterine  incision  is  completed,  the 
assistant  should  insert  his  index-fingers  into  the  upper  and  lower 
angles  of  the  wound  and  lift  the  uterus  into  close  contact  with  the 
abdominal  wall  (Winckel).  As  the  uterus  retracts  during  the  delivery 
of  the  child,  the  assistant  has  to  follow  its  movements  downward  with 
great  care,  to  avoid  protrusion  of  the  intestines. 

The  membranes  should  be  ruptured  through  the  wound,  rather 
than  through  the  vagina.  It  is  more  quickly  effected,  and  time  at  this 
stage  is  precious.    The  escape  of  the  amniotic  fluid  into  the  abdomen 


CJ3SAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.  403 


can  be  avoided  by  a  dexterous  assistant.*  If  the  head  presents  at  the 
uterine  opening,  it  should  be  seized  and  drawn  out  first.  Sometimes 
the  foetus  is  expelled  spontaneously,  as  in  natural  labor,  by  the  uterine 
contractions.  Usually  it  is  necessary  to  introduce  the  hand  and  seize 
one  or  both  lower  extremities.  The  extraction  of  the  child  by  the 
breech  is  performed  in  the  usual  way.  The  delivery  should  not  be 
too  rapid,  but  should  be  graduated  so  as  to  permit  the  assistant  to  ful- 
fill his  duties  in  keeping  back  the  intestines.  If,  owing  to  the  retrac- 
tion of  the  uterus,  the  head  becomes  arrested,  it  is  better  to  enlarge 
the  incision  upward  with  the  bistoury  than  to  tear  the  tissues,  f  Af- 


¥iG.  195.— Method  of  extracting  foetus. 


ter  the  removal  of  the  child,  the  cord  should  be  tied  quickly,  and  the 
child  handed  to  the  nurse.  The  mother  claims  the  entire  attention  of 
the  physician. 

When  the  placenta  is  implanted  upon  the  anterior  wall  of  the 
uterus,  it  is  liable  to  be  cut  down  upon  in  making  the  Csesarean  sec- 
tion. This  accident  occurs  about  once  in  three  cases.  J:  It  occasions, 
for  the  time  being,  enormous  haemorrhage.    The  bleeding  begins  with 

*  The  escape  of  a  small  quantity  of  amniotic  fluid  into  the  abdomen  is  of  no  great 
consequence,  as  it  is  for  the  most  part  bland  and  unirritating. 

f  Owing  to  the  presence  of  large  veins  in  the  neighborhood  of  the  os  internum,  a 
tearing  of  the  lower  angle  of  the  wound  is  apt  to  be  followed  by  persistent  haemorrhage. 
When  such  an  accident  occurs,  it  is  best  to  bring  the  wound  together  with  fine  sutures, 
as  no  reliance  can  be  placed  upon  the  contractile  action  of  the  cervical  tissues. 

X  Stoltz,  "  Dictionnairc  de  M(5d.  etde  Chir.,"  t.  vi,  art.  "  Operation  Cesaricnne,"  p.  700. 


404 


OBSTETRIC  SURGERY. 


the  division  of  the  outermost  layer  of  muscular  fibers.  It  is,  however, 
necessary  to  complete  the  incision  to  the  placenta,  and  then  to  detach 
the  latter  upon  one  side  until  the  hand  can  pass  into  the  uterine 
cavity.  The  extraction  of  the  child  furnishes  the  only  effective  means 
of  controlling  the  haemorrhage.* 

In  addition  to  the  directions  already  given  for  guarding  against 
the  escape  of  the  intestines,  it  is  sometimes  useful  for  the  assistants  to 
press  the  uterus  out  of  the  abdominal  opening.  This  method  has  the 
further  advantage  of  preventing  bleeding  into  the  abdominal  cavity 
during  the  extraction  of  the  placenta  and  pending  the  retraction  of 
the  uterus.  Of  course,  the  assistant  has  at  the  same  time  to  see  that 
the  cut  surfaces  of  the  abdomen  are  kept  in  close  contact  with  the 
uterine  walls.  If  from  negligence,  or  from  unavoidable  causes,  a  pro- 
trusion of  the  intestines  should  take  place,  the  assistant  remains  pas- 
sive, while  their  replacement  becomes  the  charge  of  the  operator. 

3.  In  case,  after  the  delivery  of  the  child,  the  haemorrhage  ceases, 
the  uterus  may  be  wrapped  in  a  warm  cloth,  moistened  with  a  weak  so- 
lution of  carbolic  acid,  and  a  short  respite  allowed  before  proceeding 
to  the  manual  removal  of  the  placenta,  as  its  extrusion  is  often  sponta- 
neously effected  by  the  contractions  of  the  uterus.  After  five  to  ten 
minutes  have  elapsed,  or,  in  case  the  haemorrhage  continues,  immedi- 
ately after  the  extraction  of  the  child,  the  uterus  should  be  gently 
kneaded  while  tractions  are  made  upon  the  cord.  If  needful  it  is 
allowable  to  introduce  the  fingers  into  the  wound  to  separate  the  pla- 
centa and  membranes.  Every  pains  should  be  taken  to  detach  the 
membranes  entire.  After  the  complete  removal  of  the  ovum,  the 
fingers  should  be  introduced  into  the  uterus  to  turn  out  clots  and 
stimulate  contractions.  Finally,  the  uterine  wound  should  be  closed 
with  sutures.  If,  owing  to  imperfect  contraction,  haemorrhage  con- 
tinues after  the  uterus  has  been  emptied,  the  suture  is  the  safest  haemo- 
static in  our  possession.  Prolonged  frictions  of  the  fundus  and  the 
applications  of  ice  are  apt  to  increase  the  shock  of  the  operation  and 
to  excite  peritonitis.  But  even  where,  at  the  conclusion  of  the  opera- 
tion, the  uterus  is  well  retracted,  and  the  haemorrhage  arrested,  it  is 
well  to  still  use  the  suture  as  a  prophylactic  against  secondary  haemor- 
rhage. In  many  fatal  cases  the  uterine  wound  has  been  found  gaping, 
so  that  the  lochia  had  escaped  into  the  peritoneal  cavity.  The  deep 
sutures  should  be  inserted  a  half-inch  from  the  cut  borders,  and  at 
intervals  of  an  inch  from  one  another.    Superficial  sutures,  designed 

*  It  is  usual  to  caution  against  cutting  through  the  placenta.  Spiegelbcrg  ("  Iland- 
buch  der  Gcburtshiilfe,"  p.  858),  who,  in  three  of  his  cases,  cut  down  upon  the  placenta, 
found  the  direction  to  separate  the  latter  with  the  hand  a  very  difficult  thing  to  follow. 
The  fingers  tore  through  the  placenta  without  detaching  it,  so  that  in  the  end  he  was 
obliged  to  cut  through  the  vascular  organ  to  the  membranes.  Of  course,  the  more  rap- 
idly the  operation  is  performed,  the  less  the  hasmorrhage  ensuing. 


CiESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.  405 

to  approximate  the  peritoneal  edges,  should  be  introduced  between 
the  deep  ones.  Much  ingenuity  has  been  employed  in  devising  a 
suture  capable  of  being  withdrawn  a  few  days  after  the  operation 
through  the  abdominal  walls.  As,  however,  experience  in  the  extir- 
pation of  ovarian  tumors  has  shown  that  ligatures  may  be  safely 
abandoned  wdthin  the  peritoneal  cavity,  preference  is  now  given  to  the 
ordinary  interrupted  suture.  The  material  used  should  be  carbolized 
silk,  as  it  cuts  less  than  silver  wire.  Catgut  has  been  found  imprac- 
ticable, as  the  knots  are  apt  to  become  loosened  by  the  alternate  con- 
traction and  relaxation  which  normally  take  place  in  the  uterus  after 
confinement. 

After  the  sutures  have  been  introduced,  and  the  haemorrhage 
checked,  the  uterus  should  be  returned  to  the  abdominal  cavity. 
Long  sponge-holders,  armed  with  sponges  which  have  been  soaked  in 
warm  carbolized  fluid,  should  then  be  employed  to  cleanse  the  vis- 
ceral and  parietal  surfaces  of  the  peritonaeum,  and  to  soak  up  any  free 
fluid  in  the  cul-de-sac  of  Douglas. 

4.  The  abdominal  wound  may  be  closed  by  either  silk  or  wire  sutures. 
The  sutures  should  be  introduced  an  inch  to  an  inch  and  a  half  apart. 
They  should  be  inserted  rather  more  than  an  inch  from  the  border  of 
the  wound,  and  should  slope  toward  the  inner  surface,  yet  so  as  to  in- 
clude upon  each  side  a  narrow  strip  of  peritonaeum.  Superficial  sutures 
should  be  added  to  complete  the  adaptation  of  the  wounded  surfaces 
to  one  another.  After  carefully  washing  the  abdomen,  the  wound  is 
covered  first  by  a  layer  four  inches  in  breadth  of  protective  silk,  and 
afterward  by  six  to  eight  la3^ers  of  antiseptic  gauze.  The  entire  abdo- 
men should  then  be  padded  over  with  one  or  two  layers  of  cotton- 
wool, and  supported  by  a  firm  bandage  of  unbleached  muslin.  For 
three  or  four  days  the  dressings  do  not  usually  require  to  be  disturbed. 
When,  however,  the  antiseptic  gauze  shows  evidence  of  soiling  from 
the  wound-secretion,  it  should  be  replaced  under  carbolized  spray.  In 
case  it  should  be  thought  desirable  to  insert  a  glass  drainage-tube  into 
the  lower  angle  of  the  abdominal  wound,  the  antiseptic  treatment  may 
be  carried  out  by  adopting  a  device  of  Dr.  Keith  in  ovariotomy.  Dr. 
Keith  makes  a  small  incision  in  a  piece  of  thin  rubber  sheeting, 
through  which  the  drainage-tube  is  passed.  After  the  latter  is  in- 
serted into  the  abdomen,  a  sponge  soaked  in  carbolic  fluid  (1:20)  is 
placed  over  the  mouth  of  the  tube.  The  rubber  is  then  reflected 
over  the  sponge,  which  is  thus  kept  from  getting  dry,  while  at  the 
same  time  a  carbolized  vapor  at  the  mouth  of  the  tube  preserves  the 
peritoneal  cavity  from  the  penetration  of  septic  germs.  Of  course, 
every  subsequent  examination  of  the  tube  should  be  made  under  car- 
bolic spray. 

The  writer  is  fully  aware  that  it  is  not  possible  to  realize  in  every 
case  all  the  conditions  and  all  the  precautions  contained  in  the  fore- 


406 


OBSTETRIC  SURGERY. 


going  directions.  Perhaps  the  majority  of  past  operations  have  been 
performed  after  the  woman  has  been  days  in  labor,  after  the  rupt- 
ure of  the  membranes  and  the  retraction  of  the  uterus,  after  the  lower 
uterine  segment  has  been  subjected  to  prolonged  pressure  between  the 
child's  head  and  the  pelvic  brim,  without  adequate  assistance,  without 
antiseptic  precautions,  and  with  only  the  instruments  of  the  physician's 
pocket-case.  The  uterine  suture  is  rejected  by  many  to-day,  as  indeed 
was  the  case  with  the  abdominal  suture  in  the  early  history  of  the  op- 
eration. And  yet  it  can  hardly  be  hoped  that  the  reproach  which  sur- 
rounds the  Caesarean  section  will  be  removed  until,  in  its  performance, 
the  rude  methods  of  the  veterinary  art  are  replaced  by  the  j)rocedures 
of  scientific  surgery.  In  reading  the  histories  of  many  of  the  bygone 
operations,  we  can  not  but  agree  with  Mauriceau  in  thinking  that,  "if 
it  is  true  that  any  women  have  escaped,  it  was  the  work  of  a  miracle, 
or  the  express  wish  of  God,  who,  if  he  wills  it,  is  able  to  raise  the  dead, 
as  he  did  Lazarus,  .  .  .  rather  than  by  any  etfect  of  human  prudence."* 

The  After-Treatment. — The  after-treatment  is  conducted  upon  the 
same  princiiDles  as  those  followed  in  ovariotomy.  The  patient  should 
be  isolated,  and  perfect  quiet  maintained.  A  nurse  should  be  in  con- 
stant attendance.  The  circulation  should  be  stimulated  by  the  appli- 
cation of  warmth  to  the  surface  of  the  body,  especially  to  the  extremi- 
ties. Pain  should  be  subdued  by  opiate  suppositories  or  subcutaneous 
injections  of  morphia.  In  vomiting,  following  the  operation,  only  ice, 
or  a  teaspoonful  of  ice-water  at  intervals,  should  be  allowed  by  the 
mouth.  Until  the  stomach  becomes  quiet,  nutrition  should  be  main- 
tained by  rectal  alimentation.  The  diet  during  the  first  week  should 
consist  of  milk,  beef-tea,  and  other  fluid  forms  of  food.  The  catheter 
should  be  passed  every  six  hours,  until  the  patient  is  able  to  void  her 
water  voluntarily  without  straining.  The  bowels  should  be  kept  con- 
fined for  at  least  the  first  five  days.  Only  in  very  exceptional  cases 
should  lactation  be  permitted.  During  the  first  three  to  four  days, 
where  antiseptics  have  been  used,  it  is  not  necessary  to  disturb  the 
dressings.  The  superficial  sutures  may  be  removed  under  spray  on  the 
fifth  day,  the  deep  sutures  should  be  gradually  removed  between  the 
seventh  and  tenth  days.  Peritonitis,  septicaemia,  and  shock  are  to  be 
treated  according  to  the  usual  rules. 

Prognosis. — We  have  already  alluded  to  the  formidable  character  of 
the  Caesarean  operation.  Michaelis  f  collected  258  authentic  cases,  of 
which  54  per  cent,  ended  in  recovery.  Kayser  I  added  80  new  cases 
to  those  reported  by  Michaelis,  and  reduced  the  recoveries  to  38  per 
cent.     Mayer*  gathered  1,G05  cases,  with  54  per  cent,  recoveries. 

*  Baudon,  "  L'anatoniic  abdominalc,"  p.  12. 

f  Michaelis,  "  Abhandlunj^en  aus  dcm  Gebiete  dcr  Geburtshiilfc,"  1833. 

:{:  Kayser,  "Dc  Eventu  Scctionis  Caesana)."  I 

#  Mayeii,  notics  by  Bromcisl,  "  Wien.  mod.  Woch.,"  1868,  No.  61. 


CESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.  407 


Pihan-Duf eilhay  *  collected  88  cases,  published  between  1845-'49,  of 
which  57  per  cent,  ended  in  recovery.  Finally,  Dr.  Harris  has  gath- 
ered with  great  industry  the  histories  of  129  cases  performed  in 
North  America,  57  of  which,  or  oyer  44  per  cent.,  ended  in  recovery. 
Under  this  showing  it  will  be  seen  that  fully  one  half  of  all  the 
Osesarean  operations  end  fatally.  Large,  however,  as  the  mortality 
appears,  the  results  are,  I  have  no  doubt,  much  more  favorable  than 
would  be  obtained  from  a  similar  number  of  craniotomies  which 
should  include,  as  the  statistics  of  the  jCaesarean  section  do,  the 
work  of  many  unskilled  hands.  But  "it  has  been  'objected  to  the 
statistics  that  they  do  not  even  approximately  represent  the  truth. 
It  is  well  known  that  many  cases  have  never  been  included  in  the  large 
collections.  By  some  it  has  been  assumed  that  the  unpublished  and 
omitted  cases  have  all  been  fatal  ones.  Stoltz,f  however,  reports  that 
he  knew  of  five  successful  operations  not  contained  in  Kayser's  statis- 
tics, though  they  had  been  published  during  the  period  embraced  in 
his  calculations.  Harris  collected  47  cases  by  correspondence  with 
practitioners  in  various  sections  of  the  country.  Of  these,  14  ended 
in  recovery  and  33  in  death.  In  Mayer's  statistics,  the  recoveries 
from  the  operation  in  America  were  placed  at  33  per  cent.,  while, 
as  we  have  seen,  Harris  found  them  to  have  amounted  to  over  44 
per  cent.  Thus  it  is  by  no  means  certain  that  statistics  present  the 
Caesarean  operation  in  too  favorable  a  light.  The  habitual  indiffer- 
ence of  the  rural  practitioner  to  the  publication  of  his  triumphs  is 
one  of  his  besetting  sins.  While  admitting  that  the  whole  question 
is  purely  a  matter  of  speculation,  it  is,  at  the  same  time,  quite  prob- 
able that  a  goodly  number  of  successes  as  well  as  of  failures  lie  buried, 
to  use  the  words  of  Stoltz,  in  the  note-books  of  modest  physicians.  If, 
however,  we  drop  the  numerical  method  altogether,  and  devote  our- 
selves to  a  careful  study  of  the  cases  upon  which  our  statistics  are 
built,  we  leave  the  mists  of  uncertainty,  and  are  able  to  plant  our- 
selves upon  tolerably  firm  ground. 

Now,  the  first  pertinent  fact  that  strikes  as  in  examining  the  tabu- 
lated cases  of  Caesarean  section  is,  that  a  very  large  j)roportion  of  the 
entire  number  have  been  derived  from  the  reports  of  lying-in  hospitals. 
Michaelis  I  found  that  of  96  cases,  the  details  of  which  were  given  with 
sufficient  minuteness  to  leave  no  doubt  concerning  this  point,  36,  or 
rather  more  than  a  third  of  the  entire  number,  were  hospital  patients. 
With  astonishment,  too,  he  noticed  that  25  of  the  36  died,  and  that 
only  11  recovered  ;  whereas,  of  the  60  cases  in  private  practice,  only 
29  patients  died  while  31  recovered.  This  remarkable  discrepancy  in 
the  result  was  such  that  Michaelis  could  not  at  first  give  it  credence. 

*  PiHAN-DuFEiLHAY,  "  Arch.  Gen.  de  Mecl.,"  1861,  t.  il. 

-}•  Stoltz,  "  Lettre  sur  la  provocation  dc  ravortcment,"  "  Gaz.  Med.,"  1853,  p.  304. 
}  Michaelis,  loc.  cU.,  p.  156. 


408  OBSTETRIC  SURGERY. 

AYhen  he  found,  however,  that  there  was  no  possible  source  of  error  in 
his  figures,  he  sought  to  account  for  the  mortality  in  hospitals  on  the 
ground  that  the  latter  were  the  receptacles  of  all  the  most  unpromising 
and  hopeless  class  of  cases,  while  the  private  practitioner  more  often 
had  to  deal  with  women  in  good  health  and  with  slight  degrees  of  de- 
formity. Then  he  insinuates  that  the  private  physician  does  not 
usually  care  to  stake  his  reputation  upon  an  operation  which  probably 
will  terminate  fatally,  but  that,  between  weighing  the  case,  and  sum- 
moning counsel,  and  putting  off  action,  the  woman  often  dies  undeliv- 
ered before  a  defcision  is  reached.  Kayser's  results*  were  even  worse 
than  those  of  Michaelis,  for  in  67  hospital  cases  he  found  the  mor- 
tality 79  per  cent.  Spaeth  says  that  there  has  not  been  a  single  case 
in  the  lying-in  hospital  in  Vienna  during  this  century  in  which  the 
mother  has  survived.  Baudon,  writing  in  1873,  says,  ^^In  Paris  there 
has  not  been  one  successful  case  in  eighty  years,  though  in  the  present 
century  the  operation  has  been  performed  on  perhaps  as  many  as  fifty 
women."  This  statement  is  often  quoted  as  a  crushing  rejoinder  to 
those  who  claim  that  the  time  has  not  yet  come  for  sweeping  the  Cae- 
sarean  section  from  the  list  of  legitimate  obstetrical  operations.  But, 
as  we  glance  over  the  list  of  operators,  and  find  fourteen  deaths  ac- 
credited to  Seutin,  seventeen  deaths  to  Paul  Dubois,  four  deaths  to 
Depaul,  three  deaths  to  Danyau,  two  deaths  to  Tarnier,  and  several 
to  Moreau,  we  find  in  the  ghastly  record  only  fresh  evidence  that  there 
is  but  little  hope  for  the  success  of  abdominal  surgery,  whatever  the 
skill  of  the  operator,  when  performed  in  the  putrid  atmosphere  of  an 
infected  hospital. 

On  the  other  hand,  the  results  of  the  Caesarean  section  in  healthy 
rural  localities  are  in  striking  contrast  with  those  obtained  in  hospitals 
or  even  in  large,  overcrowded  cities.  Thus,  Stoltz  mentions  that  in  the 
department  of  the  Creuse  the  operation  was  performed  six  times  be- 
tween the  years  1843  and  1852,  and  in  every  case  with  success,  f  Hoe- 
becke  operated  sixteen  times  in  the  country,  and,  though  his  patients 
were  poor,  and  so  scattered  that  he  was  not  able  to  visit  them  as  fre- 
quently as  was  desirable,  eleven  of  them  recovered.  Maslieurat-Lage- 
mard  operated  six  times  in  the  country;  all  of  his  patients  recovered.  | 
Prevost  had  three  successes  in  four  operations.  Cottmann  and  Boaqui 
each  had  two  successful  cases.  In  Ohio,  Harris  reports  six  recoveries 
in  eight  operations ;  in  Louisiana,  fourteen  recoveries  in  nineteen 
operations.* 

*  ri(/e  Baudon,  "  L'anatoinic  abdominale,"  p.  101. 

f  Stoltz,  op.  ciL,  p.  689,  :j:  Baudon,  "  L'anatomie  abdcninalc,"  p.  106. 

*  Harris,  "Caesarean  Cases  in  Ohio,"  "  Obstet.  Gaz.,"  September,  18*78,  p.  99; 
"  New  Orleans  Med.  and  Surg.  Jour.,"  vol.  v,  1878-"79.  In  this  article  are  related  the 
successes  quoted  above  of  Prevost  and  Cottmann.  Pilate  in  the  article  was  accredited 
with  two  successes,  but  Harris  subsequently  assigned  them  to  Boaqui. 


CESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.  409 

Now,  it  does  not  seem  logical,  when  such  successes  have  been  ob- 
tained in  certain  districts  by  certain  operators,  to  place  the  Oaesarean 
section  under  the  ban,  because  other  operators  in  other  localities  have 
failed  altogether.  No  one  reasoned,  after  the  triumphs  of  Clay,  Peas- 
lee,  and  Spencer  Wells,  that  ovariotomy  should  be  proscribed,  because 
contemporaneously  in  France  and  Germany  the  extirpation  of  ovarian 
cysts  had  been  almost  constantly  followed  by  death.  Certainly  the 
intelligent  course  to  pursue  always,  in  the  face  of  conflicting  results,  is 
to  sift  out  the  reasons  for  failure  on  the  one  hand,  and  the  conditions 
of  success  on  the  other. 

If  we  begin  by  asking  why  the  Cgesarean  section  has  so  often  ended 
fatally,  we  have  already  found  the  answer  for  many  cases  in  the  fact 
that  the  patients  were  operated  upon  in  the  impure  atmosphere  of 
maternity  hospitals.  The  frequency  with  which  gangrene  of  the  uter- 
ine wound  is  mentioned  in  the  post-mortem  records  bespeaks  the 
prevalence  and  activity  of  septic  germs.  Ovarian  patients  placed  in  the 
midst  of  similar  unwholesome  surroundings  die  almost  certainly,  in 
spite  of  the  skill  of  the  operator. 

Again,  the  accounts  of  the  cases  which  have  come  down  to  us  shed 
a  deal  of  light  upon  the  causes  of  the  untoward  results.  I  have  before 
me  the  histories  of  one  hundred  and  eight  cases  collected  by  Michaelis, 
and  published  by  him  in  1832.  They  all  belong  to  the  nineteenth 
century,  and  are  of  undoubted  authenticity.  Moreover,  they  are  in- 
cluded in  all  the  statistical  tables  which  have  since  been  published. 
In  the  entire  number,  there  were  sixty-one  deaths.  In  thirty-four  of 
the  fatal  cases,  the  histories  given  are  tolerably  explicit.  From  these 
accounts,  I  gather  the  following  suggestive  particulars  : 

Caesarean  section  performed  upon  a  corpse.  Case  of  ruptured 
uterus  ;  Caesarean  section,  the  day  following  the  rupture.  Ritgen's 
unsuccessful  case  of  laparo-elytrotomy.  As  ^'  the  strength  of  his  patient 
was  failing  fast,"  owing  to  the  haemorrhage  from  the  vaginal  wound, 
and  as  "the  contractions  of  the  uterus  had  entirely  ceased,"  the  Caesa- 
rean section  was  performed  to  save  the  life  of  the  child. 

In  five  cases  Caesarean  section  was  first  tried  after  prolonged  but 
vain  attempts  at  delivery  by  the  forceps  and  version.  In  another  it 
was  first  resorted  to  after  the  failure  of  craniotomy. 

One  operator  extended  his  incision  to  the  os  uteri. 

Two  cases  were  complicated  with  eclampsia,  and  one  with  placenta 
praevia. 

In  one  case  the  operation  was  performed  six  days  after  the  mem- 
branes had  ruptured.  The  bladder  had  to  be  previously  punctured. 
The  fa3tus  was  putrid. 

To  control  haemorrhage,  Eitgen  in  one  instance  tied  nine  arteries 
in  the  uterine  wound. 

In  one  patient  the  operation  was  deferred  until  peritonitis  had  set  in. 


410 


OBSTETRIC  SURGERY. 


There  were  two  cases  of  neglected  shoulder  presentation.  In  the 
one  the  operation  was  performed  four  days  after  the  rupture  of  the 
membranes,  and  in  the  other  thirty  hours.  In  the  latter  the  uterine 
tissues  were  found  necrosed  from  pressure  between  the  promontory 
and  the  presenting  part. 

In  one  case  the  operation  was  performed  by  violence,  in  spite  of  the 
protests  and  struggles  of  the  patient. 

There  were  a  number  of  women  upon  whom  the  operation  was 
repeated  in  a  succession  of  pregnancies.  Of  these,  two  died  after  the 
second  operation,  and  three  after  the  third.  In  one  of  the  latter 
series  the  patient  seemed  to  be  doing  well,  until  the  twenty-seventh 
day,  when  she  got  out  of  bed,  and  sat  by  an  open  window  for  an  hour 
to  watch  the  passing  of  a  troop  of  soldiers.  The  wound  gaped  open, 
and  death  followed  the  same  day. 

In  one  patient  the  first  days  of  danger  were  past  and  the  wound 
promised  to  heal  kindly,  when  the  brother,  disappointed  in  the  ex- 
pected succession  to  her  property,  beat  the  woman,  whereupon  the 
wound  tore  open,  and  fatal  fever  followed. 

In  another  case,  all  went  well  until  the  seventh  day,  when,  de- 
lighted at  the  prospect  of  recovery,  the  patient  jumped  from  bed, 
danced  around,  and  swallowed  a  pint  of  brandy. 

In  two  cases  death  resulted  from  the  protrusion  of  the  intestines 
from  the  abdominal  wound  subsequent  to  the  operation.  In  one,  this 
occurred  on  the  third  day.  The  physician,  who  operated  with  a  razor 
and  used  no  bandage  or  adhesive  straps  to  support  the  abdomen,  did 
not  see  his  patient  after  the  operation  until  the  accident  referred  to 
had  taken  place.  In  the  other,  two  inches  of  the  abdominal  wound 
were  intentionally  left  open,  vomiting  set  in,  and  the  bowels  were  forced 
through  the  gap. 

The  injurious  effects  of  protracted  labor  upon  otherwise  perfect- 
ly natural  deliveries  are  well  known.  In  contracted  pelves,  in  addi- 
tion to  the  exhaustion  and  nervous  depression  which  follow  in  long 
labors,  the  pain,  the  loss  of  sleep,  and  the  inability  to  take  food,  the 
outlook  for  the  patient  is  still  further  darkened  by  the  early  and  com- 
plete escape  of  the  amniotic  fluid,  the  consequent  retraction  of  the 
uterus  upon  the  foetus,  the  bruising  of  the  maternal  tissues  from 
pressure  of  the  child's  head,  and  at  times  from  perforation  or  even 
rupture  of  the  uterus.  A  priori,  therefore,  one  would  expect  that 
every  hour's  delay,  after  the  Csesarean  section  had  once  been  decided 
upon  as  necessary,  would  imperil  the  result.  This  deduction  is  fully 
justified  by  the  facts.  Thus  Dufeil hay's  statistics  showed  that,  when 
.  the  Csesarean  operation  is  performed  before  the  woman  becomes  ex- 
hausted, eighty-one  per  cent,  recover.  Harris  collected  twenty-six  cases 
of  timely  operation,  which  ended  in  the  saving  of  nineteen  mothers, 
or  upward  of  seventy-three  per  cent.    If,  now,  we  return  to  the  fatal 


C^SAREAJ^  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.  411 


cases  reported  by  Michaelis,  we  find,  in  addition  to  those  from  the  his- 
tories of  which  we  have  quoted,  two  operations  performed  twenty-four 
hours  after  the  rupture  of  the  membranes  :  two,  forty-eight  hours  ;  one, 
seventv-two  hours  ;  and  one,  ninety-six  hours.  Two  operations  were 
performed  two  days  from  the  beginning  of  labor  ;  two,  five  days  ;  and 
one,  eight  days. 

Thus  we  find  that,  in  more  than  one  half  of  Michaelis's  reported 
fatal  cases,  the  operation  was  performed  upon  the  dead  and  the  dying, 
or  under  circumstances  which  reduced  the  chances  of  success  to  a  slen- 
der possibility.  How  far  the  remaining  cases  are  open  to  the  same 
criticism  it  is  impossible  to  say,  owing  to  the  defectiveness  of  the  his- 
tories. 

Now,  Dr.  Barnes  says,  with  great  truth,  '^Obviously,  we  can  not 
recognize  fatal  cases  of  craniotomy  in  extreme  deformity  of  the  conju- 
gate diameter  reduced  to  2"  or  1*75",  unless  the  operation  was  begun 
under  selected  circumstances — that  is,  before  exhaustion  had  set  in — 
and  conducted  with  due  skill,  and  after  the  most  approved  methods."  * 
But  we  have  an  equal  right  to  refuse  to  recognize  fatal  cases  of  Caesa- 
rean  section  in  which  the  conditions  and  methods  of  the  operation 
rendered  success  an  improbable,  if  not  an  impossible  issue. 

PoRRo's  Operation^  AND  Laparo-Elytrotomy. 

While  objection  may  be  fairly  taken  to  the  disfavor  with  which 
the  Caesarean  section  is  commonly  regarded  among  English-speaking 
races,  it  can  not  be  denied  that  it  is  open  to  one  strong  objection,  viz., 
that  the  results  in  the  end  depend  upon  the  efficiency  of  the  uterine 
contractions  subsequent  to  the  operation.  When  the  operation  is  per- 
formed early  in  labor,  after  the  pains  are  well  established,  but  before 
the  patient's  strength  is  exhausted,  and  when  the  sutures  have  been 
introduced,  art  has  done  all  that  it  can  accomplish  to  prevent  gaping 
of  the  uterine  wound.  But,  even  when  these  precautions  have  been 
scrupulously  observed,  imperfect  retraction  of  the  uterus  or  a  cutting 
out  of  the  sutures  may  leave  an  open  communication  between  the  uter- 
ine and  abdominal  cavities.  As  the  uterine  section  in  itself  is  apt 
to  excite  a  considerable  degree  of  catarrhal  endometritis,  and  as  the 
admission  of  air  into  the  uterus  furnishes  the  condition  for  decom- 
position of  the  lochia,  the  patient  is  always  exposed  to  the  dangers 
arising  from  penetration  of  septic  materials  into  the  peritoneal  sac. 
Porro's  operation  and  laparo-elytrotomy  have  both  been  designed  to 
avoid  the  risks  incident  to  this  cause. 

Porro's  Operation,  or  Ovaro-Hystoreectomy.— The  characteristic 
feature  of  the  Porro  operation  consists  in  the  removal,  after  the  per- 
formance of  the  Caesarean  section,  of  both  uterus  and  ovaries.  As 
the  result  of  experiments  upon  animals,  its  theoretical  practicability 
*  Barnes,  "  Obstetrical  Operations,"  D.  Appleton  &  Co.,  p.  418. 


412 


OBSTETRIC  SURGERY. 


was  demonstrated  as  early  as  1769  by  Cavallini,  and  later,  in  1823, 
by  Blundell.  Gr.  Ph.  Michaelis  in  1809,  after  referring  to  the  dan- 
ger from  reaction  following  injury  to  any  of  the  abdominal  viscera, 
goes  on  to  say  :  "  That  the  danger  specially  depends  upon  this  reac- 
tion, we  see  not  only  from  the  often  greater  associated  disorders  in 
other  organs,  but  from  the  experience  that,  when  the  uterus  has  been 
removed  so  that  the  reaction  in  other  organs  falls  away,  the  danger 
appears  to  be  much  lessened.  Several  cases  are  known  where  the 
uterus  has  been  excised  by  ignorant  persons  without  the  occurrence 
of  violent  disturbances  [Zufalle].  ...  It  is  a  question,  therefore, 
whether  the  Csesarean  section  would  not  be  rendered  less  dangerous 
by  connecting  with  it  the  extirpation  of  the  uterus."  The  ablation  of 
the  uterus  after  Caesarean  section  was  not,  however,  actually  executed 
upon  the  living  human  female  until  1868.  This  first  operation  was 
performed  by  Dr.  Horatio  E.  Storer,  of  Boston,  in  the  case  of  a  pa- 
tient whose  delivery  was  rendered  impossible  by  the  natural  passages, 
owing  to  a  large-sized  fibro-cystic  tumor  blocking  up  the  pelvic  cav- 
ity. The  haemorrhage  which  followed  the  incision  into  the  uterine 
cavity  proving  frightful,  Dr.  Storer  ligatured  the  cervix,  and,  having 
applied  the  chain  ecraseur,  slowly  removed  the  mass.  Both  the  child 
and  placenta  were  in  a  state  of  decomposition.  The  patient  lived 
sixty-eight  hours.  At  the  time  of  the  occurrence  the  hardihood  of 
the  operator  was  the  subject  of  a  good  deal  of  unfavorable  com- 
ment. 

In  1874  Professor  Edward  Porro,  of  Pavia,  having  succeeded  in 
preserving  the  lives  of  animals  from  which  he  had  removed  the  gravid 
uterus,  decided  that,  as  soon  as  a  chance  offered,  he  would  add  to  the 
Caesarean  section  as  a  completive  measure  the  ablation  of  the  uterus 
and  its  appendages.  The  sought-for  opportunity  presented  itself  on 
the  21st  of  May,  1876.  The  patient  had  a  rachitic  pelvis,  with  an 
antero-posterior  diameter  reduced  to  one  inch  and  a  half.  The  child 
was  extracted  living,  and  the  mother  survived.  After  the  publication 
of  Porro's  report,  the  two  Brauns  and  Spaeth,  of  Vienna,  where  the 
Caesarean  section  had  been  proverbially  fatal  (no  case  saved  in  this 
century),  resolved  to  give  the  new  operation  a  trial.  Spaeth  led  off 
with  a  success  in  June,  1877.  Since  then  I  learn,  through  a  private 
communication  from  Dr.  E.  P.  Harris,  who  has  with  untiring  zeal 
made  all  questions  connected  with  the  Caesarean  section  his  peculiar 
province,  that  the  number  of  operations  performed  to  the  present  time 
(June,  1881)  has  swollen  to  71,  of  which  30  have  ended  in  recovery, 
and  41  in  death. 

These  results,  though  they  still  leave  much  to  be  desired,  are  en- 
couraging when  we  remember  that  they  have  for  the  most  part  been 
obtained  in  lying-in  hospitals,  where  the  unmodified  Caesarean  section 
has  proved  nearly  uniformly  fatal.    As  in  all  Caesarean  operations,  the 


CiESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.  413 


statistics  contain  a  number  of  cases  where  the  doom  of  the  patient 
was  decided  in  advance  of  the  operation  itself.  In  quite  a  number  of 
cases,  too,  the  unfortunate  endings  were  apparently  the  consequence 
of  errors  of  judgment  on  the  part  of  the  operator,  against  which  it  is 
to  be  anticipated  that  it  will,  in  future,  be  possible  in  a  measure  to 
guard,  as  the  methods  of  operating  become  more  settled,  and  the  indi- 
cations for  the  operation  become  more  clearly  defined. 

Operation. — The  preparations  and  the  details  of  the  operation  are 
the  same  as  in  Caesarean  section,  with  the  exception  of  those  which 
have  reference  to  the  ablation  of  the  uterus  and,  the  prevention  of 
haemorrhage.  Careful  attention  to  the  details  of  antiseptic  surgery 
appears  to  be  essential  to  a  successful  issue.  In  Porro's  first  case  the 
abdominal  incision  was  nearly  five  inches  in  length.  After  opening 
the  uterus  and  removing  the  foetus,  the  placenta,  and  the  membranes, 
Porro  lifted  the  emptied  organ  from  the  abdomen,  and  placed  the 
serre-noeud  of  Cintrac  around  the  lower  segment,  just  above  the  os 
internum.  The  tissues  were  then  constricted  until  all  haemorrhage 
from  the  cut  uterine  surface  was  arrested.  The  uterus  was  then  cut 
away  with  a  bistoury,  the  stump  was  brought  outside  of  the  abdomi- 
nal wound,  and  held  in  position  by  strapping  the  handle  of  the  serre- 
nceud  to  the  patient's  right  thigh.  Miiller  modified  Porro's  original 
method  by  enlarging  the  first  incision  upward  sufficiently  to  enable 
an  assistant  to  lift  the  uterus  outside  of  the  abdominal  walls,  and  by 
applying  compression  above  the  cervix  (either  the  wire  ecraseur  or  the 
Esmarch  bandage)  before  opening  the  womb  and  removing  the  child. 
This  plan  offers  the  obvious  advantage  of  rendering  the  operation 
bloodless,  and  of  making  it  easy  to  prevent  the  entrance  of  the  am- 
niotic fluid  into  the  abdominal  cavity.  Breisky,  Litzmann,  Miiller, 
Tarnier,  and  Elliott  Richardson,  of  Philadelphia,  found  no  difficulty 
in  thus  drawing  the  uterus  outside  the  abdominal  cavity  ;  Spaeth, 
Wasseige,  Tibone,  Chiara,  and  Carl  Braun,  on  the  contrary,  either 
encountered  great  difficulties  in  performing  the  manoeuvre,  or  were 
obliged  to  abandon  it  altogether.  The  modification  is  an  important 
one,  but  is  of  limited  applicability.  The  compressors  which  have  so 
far  been  employed  are  the  Cintrac  serre-nmud,  the  chain  ecraseur  with 
a  Pean  attachment  rendering  it  possible,  after  detaching  the  chain 
from  the  handle,  to  maintain  the  constriction,  and  the  various  forms 
of  wire  ecraseur.  Compression  should  be  made  slowly,  and  should  not 
be  carried  to  the  extent  of  cutting  through  the  peritonaeum.  Owing 
to  the  liability  of  wire  to  break,  great  care  should  be  taken  in  its  selec- 
tion. In  case  of  accident,  a  second  instrument  should  be  held  in  readi- 
ness. I  am  not  aware  that  the  clamp  has  thus  far  been  tested.  Yet 
it  is  hard  to  see  why  a  good  clamp  exercising  concentric  pressure,  like 
that  of  T.  G.  Thomas,  for  instance,  would  not  prove  practically  use- 
ful. 


414 


OBSTETRIC  SURGERY. 


Levy,*  gathering  together  the  results  of  past  operations,  recom- 
mends, as  most  deserving  of  imitation,  an  abdominal  incision  six  to 
seven  inches  in  length the  uterus  to  be  raised  where  it  can  be  accom- 
plished without  violence  ;  the  abdominal  wound  to  be  pressed  together 
and  covered  with  flannels  or  sponges  wrung  out  in  warm  carbolized 
water,  to  absorb  moisture  and  to  prevent  chilling  of  the  intestines  ;  the 
constrictor  then  to  be  applied  so  as  to  include  both  ovaries,  and  the 
child  to  be  extracted  rapidly ;  or,  in  case  the  uterus  can  not  be  dis- 
lodged easily  and  brought  through  the  abdominal  wound,  after  the 
size  of  the  uterus  has  been  reduced  by  rupture  of  the  membranes  jt^er 
vaginam  the  assistant  in  charge  should  use  the  precautions  already 
detailed  in  connection  with  the  Caesarean  section  against  allowing 
fluid  to  enter  the  abdominal  cavity,  and  after  the  emptied  uterus  has 
been  raised  from  the  abdomen  he  should  temporarily  compress  the 
vessels  above  the  cervix  with  the  fingers  of  both  hands.  When  the 
constrictor  has  been  adjusted  and  all  haemorrhage  arrested,  the  stump 
should  be  trimmed  with  scissors  and  mummified  with  the  perchloride 
of  iron.  To  prevent  the  ligature  from  slipping,  and  to  sustain  the 
pedicle,  two  long  steel  pins  should  be  passed  through  the  cervix  and 
allowed  to  rest  upon  the  abdominal  walls.  Elliott  Eichardson  f  em- 
ployed pins  about  five  inches  in  length  and  of  the  size  of  a  T^o.  8  bou- 
gie, French  scale.  Of  these  he  passed  one  below  and  the  other  above 
the  wire,  and  diagonally  to  the  line  of  the  abdominal  wound.  He 
then  tied  ^^a  piece  of  stout  silk  cord  previously  soaked  in  carbolized 
oil  (one  part  to  eleven)  around  the  cervix  between  the  two  pins,  and  in 
the  line  of  the  temporary  wire  loop,  which  latter  was  removed  as  soon 
as  the  permanent  ligature  was  applied,  but  before  it  was  finally  fast- 
ened. The  silk  ligature  was  wrapped  twice  around  the  cervix,  and 
then  tied."t 

It  should  be  here  mentioned  that  on  the  second  or  third  day  the 
pulse  becomes  irregular  and  oscillates  between  one  hundred  and  one 
hundred  and  forty  pulsations  without  a  corresponding  rise  in  the  tem- 
perature, a  nervous  disturbance  attributed  by  Lucas-Championniere  * 
to  the  dragging  of  the  pedicle.  The  separation  of  the  stump  occurs 
from  the  twelfth  to  the  fifteenth  day. 

*  Levy,  "  Ucber  die  Methode  des  Kaiserschnittcs  nach  Porro,"  "  Wiener  Klinik," 
Heft  xi  und  xii. 

f  Elliott  Richardson,  "  Caesarean  Section,  with  Removal  of  Uterus  and  Ovaries,  after 
the  Porro-Miiller  Method,"  "Am.  Jour,  of  the  Med.  Sci.,"  January,  1881. 

X  All  attempts  to  drop  the  pedicle  into  the  peritoneal  cavity  have  thus  far  proved 
fatal.  In  a  remarkable  case  reported  by  Professor  I.  E.  Taylor,  the  patient  lived  twenty- 
six  days.  On  the  seventeenth  day  phlegmasia  dolens  was  developed,  which  was,  how- 
ever, rapidly  improving,  when  the  womaij,  who  was  somewhat  unruly,  after  sitting  up  in  a 
rocking-chair  against  orders,  was  suddenly  seized  with  dyspnoea,  and  died  in  a  few  hours 
from  pulmonary  embolism. — {Vide  "Am.  Jour,  of  the  Med.  Sci.,"  July,  1880.) 

*  Maygrieu,  "  Etude  de  I'operation  de  Porro,"  Paris,  1880,  p.  33. 


CESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.  415 


The  sterilization  of  the  female  as  the  result  of  amputating  the 
uterus  has  been  discussed  from  its  moral  aspect.  Few  persons  in  this 
country  are  likely,  however,  to  be  restrained  in  its  performance  by 
the  extremely  rare  cases  where  the  older  operation  has  been  success- 
fully carried  out  a  number  of  times  upon  the  same  individual. 

The  chief  merit  of  the  method  of  Porro  lies  in  the  fact  that  each 
step  in  the  operation  is  capable  of  human  control,  and  is  capable, 
•therefore,  of  human  improvement. 

Thomas's  Operation,  or  Laparo-Elytrotomy. — In  Professor  Thomas's 
operation,  the  dangers  of  opening  into  the  peritonseum  and  wounding 
the  uterus  are  avoided  by  incising  the  walls  of  the  abdomen  in  the  line 
of  Poupart's  ligament,  lifting  the  peritonaeum,  and  dissecting  down  to 
the  vagina,  dividing  the  vagina  transversely,  and  then,  having  reached 
the  cervix,  extracting  the  child  through  the  passage  thus  artificially 
created. 

The  credit  of  defending  the  practicability  of  the  extra-peritoneal 
delivery  of  the  child  above  the  pelvic  brim  belongs  chronologically  to 
Ritgen.  It  was  the  natural  outcome  of  the  teachings  of  Abernethy 
and  Cooper,  to  whom  we  owe  the  ligation  of  the  external  iliac  artery 
without  opening  the  peritonaeum.  The  modus  operandi  was  carefully 
thought  out  by  Ritgen,  and  was  put  by  him  to  the  practical  test  Octo- 
ber 1,  1821.  The  incision  through  the  vagina,  which  was  made  with 
a  sharp  bistoury  in  a  longitudinal  direction,  was,  however,  followed  by 
such  profuse  haemorrhage  that  the  operation  was  discontinued,  and 
the  ordinary  Caesarean  section  performed  in  its  place.  The  patient 
died  at  the  end  of  fifty-eight  hours.* 

In  1823  Baudelocque  the  younger,  unaware  of  the  Avork  of  his  pred- 
ecessor, advised  an  incision  down  to  the  peritonaeum  along  the  exter- 
nal edge  of  the  rectus  muscle,  extending  from  the  umbilicus  to  two 
inches  above  the  pubes,  separating  the  peritonaeum  from  the  iliac  fossa 
with  the  finger  introduced  into  the  lower  end  of  the  wound,  incising 
the  vagina  to  a  length  of  four  and  a  half  inches,  and  then  leaving  the 
expulsion  of  the  child  to  nature,  or  extracting  it  with  the  short  for- 
ceps. In  1844  he  2)ublished  an  essay  reporting  tivo  cases  in  which  he 
had  tried  his  plan,  modified,  however,  by  substituting  the  flank  incision 
of  Ritgen  for  that  along  the  rectus  muscle.  Like  Ritgen,  Baudelocque 
did  not  complete  his  first  operation,  owing  to  the  extent  of  the  vaginal 
haemorrhage.  In  his  second  case,  he  succeeded  in  delivering  the  child, 
which  was,  however,  dead  at  the  time  of  his  undertaking  the  operation. 
Having  accidentally  pricked  the  external  iliac  artery,  Baudelocque  tied 
the  common  iliac,  in  order  to  arrest  the  haemorrhage  thence  resulting. 
The  labor  was  likewise  complicated  by  convulsions.    Death  took  place 

*  For  the  particulars  of  this  and  the  succeeding  cases,  the  writer  is  indebted  to  Dr. 
Henry  J.  Garrigues's  model  essay  "  On  Gastro-Elytrotomy,"  "  N.  Y.  Med.  Jour.,"  October 
and  November,  IS'ZS. 


416 


OBSTETKIC  SURGERY. 


on  the  fourth  day.  The  merit  of  first  performing  laparo-elytrotomy 
belongs,  therefore,  to  Baudelocque. 

In  1837  Sir  Charles  Bell,  in  his  Institutes  of  Surgery,"  suggested 
practically  the  same  plan  of  procedure  as  that  subsequently  advocated 
by  Dr.  Thomas. 

In  1870  Dr.  Thomas,  who  was  at  the  time  unaware  of  the  labors 
of  his  predecessors,  read  a  memorable  paper  before  the  Medical  Asso- 
ciation of  Yonkers,  giving  an  account  of,  first,  laparo-elytrotomy  per- 
formed tentatively  upon  the  cadaver  of  a  woman  dying  in  the  ninth 
month  of  pregnancy  ;  and,  second,  upon  a  living  woman  at  the  end  of 
the  seventh  month  of  pregnancy,  who  had  been  suffering  from  pneu- 
monia for  a  week  or  ten  days,  and  was  at  the  time  of  his  visit  in  ar- 
ticulo  mortis.  The  operation  was  undertaken  in  the  interest  of  the 
child,  which  was  extracted  alive,  and  survived  about  an  hour.  In 
1874  the  operation  was  repeated  by  Dr.  Skene.  The  patient  had  been 
forty-eight  hours  in  labor,  and  unsuccessful  attempts  at  delivering  her 
by  craniotomy  had  been  resorted  to.  She  was  suffering  at  the  time  of 
the  operation  from  exhaustion  and  shock,  which  gradually  became 
more  marked,  and  she  died  seven  hours  after.  In  1875  and  in  1877 
Dr.  Skene  had  the  glory  of  successfully  performing  the  operation  under 
circumstances  of  great  difficulty,  with  the  result  in  each  case  of  saving 
the  lives  of  both  mother  and  child.  In  1877  Dr.  Thomas  had  the 
good  fortune  to  obtain  a  like  triumph.  In  England  the  operation  has 
been  performed  by  Drs.  Himes  and  Edes,  both  times  in  the  interest  of 
the  child,  the  condition  of  the  mothers  being  wellnigh  hopeless. 
Both  children  were  saved.  In  1880  Dr.  Walter  R.  Gillette  *  extracted 
by  laparo-elytrotomy  a  putrid  child,  which  he  was  obliged  to  perforate 
and  extract  with  the  cephalotribe,  the  forceps  and  version  having  been 
previously  tried  without  success.  The  mother  recovered  with  scarcely 
an  untoward  symptom. 

The  foregoing  results  present  scarcely  a  parallel  in  obstetric  sur- 
gery. They  ought  certainly  to  inspire  the  profession  with  a  confidence 
at  least  equal  to  that  enjoyed  by  the  rival  procedure  of  Porro. 

The  question  to  be  decided  in  the  future  is,  as  to  how  far  laparo- 
elytrotomy  is  adapted  to  general  usage.  It  is  possible  that  the  suc- 
cesses so  far  obtained  have  been  largely  due  to  the  exceptional  merits 
of  the  operators  who  have  undertaken  it.  With  the  present  experience 
it  would  seem  as  though  it  ought  to  receive  the  preference  in  all  cases, 
where  the  dilatability  of  the  cervix  is  such  as  to  allow  delivery  by  for- 
ceps or  version,  after  the  artificial  passage  has  been  formed,  to  be  ac- 
complished with  ease  and  celerity. 

The  vaginal  ha3morrhage  noted  in  the  cases  of  Eitgen  and  Baude- 
locque can  apparently  bo  avoided  by  tearing  the  vagina  transversely, 

*  Gillette,  "  A  Successful  Case  of  Laparo-Elytrotomy,"  "  Am,  Jour,  of  Obstct.,"  Jan- 
uary, 1880,  p.  98. 


CJi:SAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.  417 


as  recommended  by  Thomas,  in  place  of  incising  it  with  a  bistoury. 
In  three  of  the  cases  vesico-vaginal  fistulae  were  produced,  but  all  healed 
spontaneously.  The  following  description  of  the  operation  is  borrowed 
from  the  excellent  essay  of  Dr.  Garrigues,  which  has  already  been 
quoted.  It  has  received  the  sanction  of  Drs.  Thomas,  Skene,  and  Gil- 
lette, with  the  exception  that,  in  discussion,  all  have  agreed  that  it  is 
desirable  to  insert  a  perforated  drainage-tube  through  the  abdominal 
wound  into  the  vagina,  and  to  keep  the  parts  cleansed  with  antiseptic 
injections. 

Operation. — The  bowels  having  been  emptied  by  an  aperient  and 
a  copious  enema,  and  the  os  having  been  fully  dilated  by  Barnes's 
water-bags,  if  it  is  not  so  already,  the  patient  is  placed  on  her  back, 
on  a  long,  narrow  table  covered  with  a  mattress  or  quilts,  rubber  or 
oil-cloth,  and  a  sheet.  The  pelvis  is  well  elevated  on  a  hard  cushion, 
the  head  and  shoulders  slightly  raised  by  means  of  pillows,  the  legs 
stretched  out.  If,  from  some  cause,  it  has  been  impossible  to  dilate 
the  OS  fully  by  Barnes's  dilators,  it  is  now  done  by  the  fingers,  or,  if 
that  is  impossible  too,  it  is  dilated  later  through  the  abdominal  wound. 
The  patient  is  anaesthetized.  Since  disinfection  can  not  be  carried 
out  strictly,  and  since  its  administration  would  give  some  additional 
trouble,  it  is  scarcely  necessary  to  operate  under  disinfectant  spray. 

The  operator  takes  his  place  at  the  right  side  of  the  patient.  Be- 
sides one  who  administers  the  anaesthetic,  four  assistants  are  needed  ; 
one  on  either  side  of  the  operator,  and  two  in  front  of  him.  The  first 
assistant,  standing  at  the  left  of  the  patient's  chest,  lays  his  flat  hands 
under  the  umbilicus  and  draws  the  uterus  upward  and  toward  the 
left,  thereby  putting  the  skin  in  the  right  iliac  region  on  the  stretch. 
Counter-extension  may  be  made  by  the  assistant  placed  at  the  right  of 
the  operator.  A  slightly  curved  incision  is  made  through  the  skin 
from  a  point  one  inch  and  three  quarters  (4*5  centimetres)  above  and 
outside  the  spine  of  the  pubes,  parallel  to  and  an  inch  above  Pou- 
part's  ligament,  to  a  point  an  inch  above  the  anterior  superior  spine 
of  the  ilium.  This  incision  may  also  be  made  in  the  opposite  direc- 
tion, from  without  inward.  By  a  few  touches  with  the  edge  of  the 
knife  the  external  oblique  muscle  is  laid  bare,  and  spouting  branches 
of  the  superficial  epigastric  artery  secured  by  holding-forceps.  The 
abdominal  muscles  are  cut  to  the  same  extent,  layer  by  layer,  the  ex- 
ternal oblique,  the  internal  oblique,  and  the  transversalis,  the  first  of 
which  is  aponeurotic.  The  transversalis  fascia  is  very  carefully  hooked 
up  with  a  fine  tenaculum,  and  the  knife  carried  horizontally,  so  as  to 
make  a  small  opening  in  it,  avoiding  the  peritonaeum  that  lies  be- 
neath it,  separated  from  it  by  loose  areolar  tissue,  and  sometimes  fat. 
A  director  is  introduced  through  the  opening  and  pushed  between  the 
fascia  and  the  peritonaeum  toward  the  inner  and  the  outer  angle  of 
the  wound,  and  the  fascia  is  cut.  The  best  instrument  for  this  pur- 
27 


418 


OBSTETRIC  SURGERY. 


pose  is  Key's  hernia  director,  the  one  which  Spencer  Wells  uses  when 
incising  the  peritonaeum  in  ovariotomy.  It  is  firm,  a  quarter  of  an 
inch  (six  millimetres)  broad,  slightly  curved  on  the  flat,  well  rounded 
at  the  end,  and  has  on  its  concave  side  a  groove  that  stops  a  quarter 
of  an  inch  (six  millimetres)  from  the  point  of  the  instrument.  Next, 
the  operator  places  the  pulp  of  his  fingers  on  the  peritonaeum,  separat- 
ing it  from  the  transversalis  and  iliac  fasciae,  until  he  reaches  the 
vaginal  wall.  The  second  assistant,  placed  at  the  left  of  the  operator, 
holds  the  peritonaeum  and  intestines,  applying  a  fine,  warm  napkin 
under  his  hands,  in  order  to  be  sure  not  to  let  them  slip.  The  first 
assistant  draws  the  uterus  vigorously  upward  and  toward  the  left,  in 
order  to  expose  the  deeper  part  of  the  vaginal  wall  on  the  right  side. 
A  female  silver  catheter  is  introduced  into  the  bladder  by  the  third 
assistant,  placed  at  the  left  hip  of  the  patient  and  held  in  the  known 
direction  of  the  boundary-line  between  the  bladder  and  the  vagina, 
below  the  ureter  on  the  side  on  which  the  operation  is  being  per- 
formed. A  blunt  wooden  instrument,  something  like  the  obturator 
of  a  cylindrical  speculum,  only  longer,  is  introduced  into  the  vagina 
and  applied  above  the  linea  ileo-pectinea,  raising  the  vaginal  wall  as 
much  as  possible  into  the  abdominal  wound.  An  incision  is  made 
parallel  to  the  ileo-pectineal  line  and  the  catheter  felt  in  the  bladder, 
as  far  below  the  uterus  as  possible,  in  order  to  avoid  the  ureter  and 
Douglas's  pouch,  and  incise  where  there  are  fewest  vessels,  cutting 
down  on  the  obturator  with  Paquelin's  thermo-cautery,  the  galvano- 
caustic  knife,  or  simply  cautery-irons  (table-knives)  only  heated  to 
red  heat.  The  surrounding  parts  are  protected  by  the  application  of 
wet  compresses  around  the  place  to  be  cauterized.  The  incision  made 
by  the  cautery  is  extended  forward  toward  the  symphysis  and  back- 
ward toward  the  promontory  by  placing  the  pulj^  of  both  index-fin- 
gers perpendicularly  on  the  edges,  and  applying  the  force  in  different 
places  in  the  direction  of  the  os  uteri  and  the  ileo-peotineal  line,  so  as 
to  tear  the  vaginal  wall  as  far  forward  as  is  deemed  safe  in  regard  to 
the  bladder  and  the  urethra,  the  locality  of  which  organs  is  ascertained 
by  feeling  the  catheter  held  by  the  assistant,  and  as  far  backward  as 
the  wound  in  the  abdomen  will  allow.  Now  the  catheter  is  withdrawn, 
the  membranes  ruptured  if  the  liquor  amnii  has  not  escaped  before, 
the  uterus  tilted  as  much  as  possible  to  the  opposite  side,  and  the  os 
drawn  with  the  forefinger  into  the  iliac  fossa. 

The  operator  draws  the  child  through  the  double  wound  either  by 
simple  extraction,  or  after  turning,  or  by  applying  the  forceps,  accord- 
ing to  the  presentation  and  other  particular  circumstances.  The  pla- 
centa is  expelled  by  compressing  the  uterus,  and  withdrawn  through 
the  wound. 

If  bleeding  occurs,  the  operator  tries  to  check  it  by  applying  liga- 
tures through  the  abdominal  wound,  holding-forceps,  styptics,  or  cau- 


I 


ANOMALIES  OF  THE  EXPELLENT  FORCES.  419 

teries,  using  a  large  wooden  tubular  speculum  ;  or  a  Sims  speculum 
may,  perhaps,  give  easier  access  to  the  bleeding  vessel  than  anything 
else.  If  it  be  impossible  to  check  the  haemorrhage,  the  vaginal  wound 
must  be  firmly  tamponed  from  below  through  the  vulva  and  from  the 
abdominal  wound  with  cotton  pledgets  soaked  in  cold  water  and 
squeezed,  and  held  in  situ  by  broad  straps  of  adhesive  plaster  round 
the  abdomen,  as  after  ovariotomy.  Except  in  the  last  eventuality,  the 
bladder  is  distended  by  injecting  lukewarm  milk  in  order  to  ascertain 
if  this  organ  has  been  injured.  If  so,  the  fistula  is  immediately  sewed 
with  catgut,  which  need  not  be  removed.  The  wound  is  cleaned  by 
injecting  a  stream  of  lukewarm  carbolized  water  (two  per  cent.),  or  a 
solution  of  thymol  (two  per  thousand),  from  the  vagina  and  from  the 
abdominal  wound.  Next,  the  edges  of  the  abdominal  wound  are 
brought  together  by  interrupted  sutures,  and  the  lower  part  of  the 
abdomen  covered  with  borated  or  salicylated  cotton,  and  surrounded 
by  broad  straps  of  adhesive  plaster  fastened  to  the  hips,  as  in  ovari- 
otomy. A  pledget  of  cotton  soaked  in  carbolized  oil  (1  to  10)  is  ap- 
plied at  the  entrance  of  the  vagina." 


THE  PATHOLOGY  OF  LABOR 


CHAPTER  XXIV. 

ANOMALIES  OF  THE  EXPELLENT  FORCES. 

Precipitate  labors, — Tardy  labors. — Irregular  pains  in  the  first  stage  of  labor. — Treatment 
of  protracted  first  stage. — Irregular  pains  in  the  second  stage. — Treatment  of  pro- 
tracted second  stage. — On  the  use  of  ergot  in  labor. — Irregular  pains  in  the  third 
stage ;  treatment. — Painful  labors :  from  hysteria ;  from  rheumatism ;  from  intesti- 
nal irritation ;  from  inflammatory  changes. 

\k  physiological  labor  the  expellent  forces  are  adequate  to  over- 
come the  resistance  encountered.  Labor  becomes  pathological — 1. 
When  the  pains  are  defective  ;  2.  When  the  resistance  offered  by  the 
soft  parts  or  the  bony  pelvis  exceeds  the  limits  of  safety  to  the  mother 
or  the  child  ;  3.  When  natural  delivery  is  rendered  difficult  or  impos- 
sible, owing  to  malformations  or  malpresentations  of  the  foetus  ;  4.  In 
consequence  of  dangerous  complications,  such  as  haemorrhage,  eclamp- 
sia, and  prolapsed  funis. 

From  a  clinical  point  of  view  the  anomalies  of  the  labor-pains  are 
divisible  into  pains  in  excess,  weak  pains,  pains  attended  by  an  extreme 


420 


THE  PATHOLOGY  OF  LABOR. 


of  physical  suffering,  and  pains  complicated  by  strictures.  Physiologi- 
cally, however,  these  different  forms  are  far  from  composing  distinct 
conditions,  isolated  from  one  another.  Thus,  rigidity  of  the  os  is  always 
intensely  painful,  and  is  usually  dependent  upon  feeble  action  of  the 
expellent  forces.  There  is  no  standard  of  strength  by  which  the  weak- 
ness or  excess  of  pains  can  be  measured.  The  terms  are  always  rela- 
tive, and  are  used  with  reference  to  the  obstacles  to  be  overcome.  In 
primiparse  strong  pains  are  requisite  to  induce  softening  and  dilata- 
tion of  the  cervix.  In  multiparae  pains  may  be  intrinsically  weak,  and 
yet  suffice  to  bring  labor  to  a  prosperous  conclusion.  Much  confusion 
of  mind  is  often  occasioned  by  the  double  sense  in  which  the  term 
^'labor-pains"  is  employed.  Thus,  it  is  frequently  stated  that  the 
pains  are  good,  when  an  examination  reveals  only  a  feeble  measure  of 
uterine  contraction,  the  word  pains "  representing  nothing  more 
than  an  acute  degree  of  physical  suffering.  Clinically,  pains  are  to  be 
judged  by  the  effects  they  produce.  In  practice  it  will  be  found  con- 
venient to  study  the  various  forms  of  irregular  uterine  action  in  con- 
nection with  the  results  of  their  influence  upon  the  duration  of  labor. 
These  results  are — 1.  Precipitate  labor  ;  2.  Tardy  labor. 

Precipitate  Labors. — It  is  customary  to  ascribe  precipitate  labors  to 
an  excess  of  the  pains.  The  term  excess  is,  however,  only  relative. 
There  is  no  reason  to  believe  that  the  uterus  ever  acts  with  such  a 
degree  of  energy  as  per  se  to  constitute  a  pathological  condition.  With 
a  large,  roomy  pelvis,  a  soft,  dilatable  cervix,  a  distensible  vagina  and 
perinaeum,  labor  may  be  terminated  by  a  few  strong  pains.  Such 
rapid  deliveries  are  not  to  be  regarded  with  apprehension.  As  a 
rule,  they  are  followed  by  firm  retraction  of  the  uterus,  and  the  con- 
tinuance of  good  contractions  acts  as  a  safeguard  against  haemorrhage. 
The  puerperal  state  usually  pursues  a  favorable  course.  Aside  from 
the  inconvenience  which  sometimes  results  when,  perchance,  women 
are  suddenly  overtaken  by  labor-pains  in  the  streets  or  in  public  places, 
an  easy,  rapid  labor  is  to  be  regarded  as  one  of  the  varieties  of  normal 
labor.  Except  the  adoption  of  precautions  against  such  untoward 
accidents,  they  call  for  no  special  treatment. 

When,  however,  the  parturient  act  occurs  in  women  who  possess 
an  undue  reflex  irritability,  which  impels  them  to  an  excessive  use  of 
the  abdominal  muscles,  it  is  possible  for  serious  mischief  to  ensue. 
Thus,  if  the  patient  happens  to  be  seized  when  in  the  standing  post- 
ure, the  straining  efforts  may  throw  the  child  suddenly  upon  the 
floor ;  but  even  here  the  consequences  are  less  detrimental  than  would 
be  naturally  anticipated.  The  force  of  the  fall  is  usually  broken  by 
the  cord.  Lacerations  of  the  latter  take  place  at  a  distance  from  the 
navel,  and  are  not  followed  by  haemorrhage.  Post-partum  haemor- 
rhage, prolapse,  and  inversion  of  tlie  uterus  are  said  to  be  possible 
oocurr,ences,t  though  of  extreme  infrequency.    When  all  the  expellent 


ANOMALIES  OF  THE  EXPELLENT  FORCES. 


421 


forces  are  called  into  play  at  an  early  period  of  labor,  before  the  rigid- 
ity of  the  utero-vaginal  canal  has  been  overcome,  the  violent  straining 
has  been  known  to  cause  subcutaneous  emphysema  of  the  head  and 
neck,  to  interfere  with  the  utero-placental  circulation,  and  even  to 
produce  fracture  of  the  fetal  skull.  Excessive  straining,  before  the 
soft  parts  have  been  properly  prepared  for  the  passage  of  the  child, 
may  likewise  lead  to  lacerations  of  the  cervix,  vagina,  and  peri- 
naeum. 

The  proper  treatment  for  this  condition  is  to  lower  the  reflex  irri- 
tability by  hypodermic  injections  of  morphia ;  or,  better  still,  by  the 
production  of  complete  anaesthesia,  so  as  to  suspend  the  action  of  the 
voluntary  muscles. 

Tardy  Labors. — For  the  proper  understanding  of  labors  protracted 
beyond  the  period  of  safety  by  irregular  uterine  contractions,  it  is 
necessary  to  bear  in  mind  the  principal  features  of  normal  delivery. 
These  are,  contractions  of  the  uterus  followed  by  relaxation  and  dis^ 
tinct  periods  of  repose  ;  stretching  and  thinning  of  the  muscular  fibers 
below  the  ring  of  Bandl,  with  retraction  of  the  uterus  above  that 
point ;  softening  and  dilatation  of  the  cervix ;  the  fixation  of  the 
uterus  in  the  axis  of  the  pelvis  ;  and  the  addition  of  the  abdominal 
muscles  to  the  expellent  forces. 

The  first  requisite  of  every  normal  labor  is  that  the  pains  shall  be 
good — i.  e.,  shall  possess  a  markedly  expulsive  character.  We  have 
seen  that  for  the  uterus  to  perform  work  the  contractions  should  not 
be  continuous,  but  distinctly  rhythmical.  For  effective  work,  more- 
over, the  excursions  of  the  uterus  during  a  contraction  should  possess 
a  certain  degree  of  amplitude,  and  the  interval  between  the  contrac- 
tions should  be  sufficient  to  allow  the  nervous  system  to  recover  from 
the  shock  of  pain. 

Irregular  Pains  in  the  First  Stage  of  Labor. — In  the  first  stage  of 
labor,  pains  are  most  frequently  defective  by  reason  of  their  short  dura- 
tion. As  a  rule,  short,  cramp-like  pains  occasion  acute  suffering. 
When  they  recur  with  little  or  no  interval  between  them,  they  are  very 
exhausting  to  the  patient.  As  the  cervix  in  such  cases  is  tense  and 
rigid,  it  is  to  this  condition  that  the  delay  is  usually  attributed.  If,  how- 
ever, the  tissues  of  the  cervix  are  healthy,  the  presentation  is  normal, 
and  the  pains  preserve  their  expulsive  character,  rigidity  of  the  cervix 
is  never  an  obstacle  to  delivery.  The  activity  of  the  organic  changes 
which  lead  to  softening  and  dilatation  is  closely  related  to  the  activ- 
ity of  the  uterine  contractions.  The  exception  to  this  rule  in  primi- 
parae  is  only  apparent.  To  be  sure,  in  them  the  firm,  closely  knitted 
tissues  of  the  cervix  yield  more  gradually  to  the  dilating  forces  than 
in  multiparas.  Indeed,  in  multiparae  we  sometimes  find  the  organic 
changes  in  the  cervix  induced  by  contractions  which  have  hardly  ex- 
cited the  notice  of  the  woman  ;  but  in  primiparae,  while  good  pains. 


422 


THE  PATHOLOGY  OF  LABOR. 


under  the  reservations  mentioned,  certainly  induce  softening  of  the 
cervix,  weak  pains  effect  no  changes  in  its  tissues. 

The  uterine  contractions  may  be  abnormal  from  the  commence- 
ment of  labor  ;  more  frequently  the  loss  of  their  expulsive  character  is 
a  secondary  condition.  In  many  primiparous  women  labor  progresses 
in  an  auspicious  manner  for  a  time,  inspiring  hopes  of  a  speedy  ter- 
mination. Then  the  cervix,  which  had  previously  been  dilating  favor- 
ably, becomes  rigid,  the  sufferings  of  the  patient  during  each  contrac- 
tion are  enhanced,  and  further  advance  is  arrested.  This  transforma- 
tion is  not  to  be  accounted  for  by  a  spasm  of  the  circular  fibers  of  the 
OS,  but  is  the  result  of  secondary  changes  in  the  action  of  the  uterus 
itself.  The  right  understanding  of  the  phenomenon  in  question  ren- 
ders it  necessary  to  recall  the  physiological  fact  that  the  uterus  is 
endowed  not  only  with  contractility,  but  with  retractile  properties 
likewise.  These  are  shown  in  a  marked  way  by  the  manner  in  which 
the  uterus  closes  upon  its  contents  after  the  escape  of  the  amniotic 
fluid  ;  so,  too,  by  the  manner  in  which  the  uterus  follows  down  the 
foetus  during  the  period  of  expulsion.  Normally,  the  gradual  closure 
of  the  uterus  upon  the  ovum  leads  with  a  dilated  os  to  the  perma- 
nent formation  of  the  bag  of  waters.  Thus  it  will  be  seen  that  in 
normal  labor  retractility  is  a  wholly  beneficent  possession  of  the 
uterus.  When,  however,  from  any  cause  the  cervix  dilates  slow- 
ly, and  the  pains  are  strong  and  close  together,  as  the  uterus  re- 
tracts upon  the  stationary  ovum,  the  excursions  made  by  the  labor- 
pains  shorten,  which  thus  tend  to  assume  the  clonic  form.  The 
continuance  of  the  same  process  leads  finally  to  the  close  investment 
of  the  ovum  by  the  uterus,  when  the  only  indication  of  contractility 
which  remains  is  the  increased  hardening  of  the  uterus  at  short  in- 
tervals. These  changes  in  the  character  of  the  contractions  are 
marked  by  corresponding  changes  in  the  cervix,  the  condition  of  the 
latter  affording  an  index  of  that  of  the  entire  uterus  in  much  the 
same  way  that  a  furred  tongue  bespeaks  a  catarrhal  condition  of  the 
stomach. 

These  secondary  changes  in  the  pains  are  dependent  upon  a  variety 
of  conditions.  The  tardy  dilatation  of  the  cervix,  which  stands  in  a 
causal  relation  to  them,  may  result  from  over-distention  of  the  mem- 
branes with  amniotic  fluid,  or  from  their  firm  adhesion  to  the  walls  of 
the  uterus  around  the  os  internum — conditions  which,  in  either  case, 
interfere  with  the  stretching  of  the  lower  segment,  and  thus  lead  to 
waste  of  uterine  force  by  distributing  it  uniformly  over  the  entire 
ovum.  Again,  where  there  is  lack  of  parallelism  between  the  axis  of 
the  uterus  and  that  of  the  pelvic  brim,  the  presenting  part  may,  by 
bearing  especially  upon  the  anterior  portion  of  the  lower  uterine  seg- 
ment and  of  the  cervix,  exercise  so  little  pressure  upon  the  os  that  its 
sphincter  long  maintains  its  integrity.    Finally,  irregular  contractions 


ANOMALIES  OF  THE  EXPELLENT  FORCES. 


423 


may  be  consequent  upon  faulty  presentations,  and  upon  any  form  of 
pelvic  obstruction. 

A  special  and  dangerous  form  of  irregularity  results  when  the  mem- 
branes rupture  prematurely,  and  the  entire  amount  of  amniotic  fluid 
leaks  away.  This,  to  be  sure,  is  a  rare  event,  as  the  presenting  part, 
as  a  rule,  acts  as  a  valve  which  closes  the  lower  segment  of  the  uterus, 
and  prevents  the  amniotic  fluid  from  escaping.  When,  however,  ow- 
ing to  the  small  size,  the  uneven  shape,  or  the  hindered  descent  of  the 
presenting  part,  the  accident  in  question  takes  place,  as  a  combined 
result  of  muscular  retractility  and  the  pressure  of  the  intestines  dur- 
ing the  pains,  the  uterus  gradually  conforms  to  the  surface  of  the 
foetus.  In  this  way  the  much-dreaded  dry  labors"  are  produced. 
The  consequences  are  far-reaching.  The  retraction  of  the  muscular 
fibers  about  the  child's  neck  in  head  presentations  forms  an  impediment 
to  natural  delivery  ;  the  disturbance  of  the  utero-placental  circulation 
endangers  the  life  of  the  child  ;  the  uterine  walls  applied  to  the  convex 
surfaces  of  the  child  become  anaemic,  while  the  reentrant  portions, 
subjected  to  negative  pressure,  become  hyperaemic  and  oedematous, 
extravasations  take  place  into  the  tissues,  the  walls  are  rendered  fri- 
able, the  contractions  are  associated  with  intense  pain,  and  peritoneal 
irritability  develops.  * 

The  prolonged  retraction  of  the  uterus  may  be  followed  in  the  end 
by  the  entire  cessation  of  pains,  and  paralysis  may  ensue.  Uterine 
retractility  is  not  precisely  the  same  force  as  that  which  causes  the 
expulsion  of  a  fluid  from  an  over-distended  elastic  sac,  for  retractil- 
ity and  contractility  are  in  the  uterus  barely  disassociated  from  one 
another.  When  the  uterus  ceases  to  contract,  it  forfeits,  as  a  rule, 
its  retractile  properties  likewise,  f  It  sometimes  follows,  therefore, 
that,  following  prolonged  tonic  contraction,  after  the  evacuation  of  the 
uterus,  the  walls  of  the  latter  collapse  like  those  of  a  pricked  bladder. 

The  Treatment  of  a  Protracted  First  Stage. — The  treatment  of  a 
protracted  first  stage  has  for  its  object  the  mitigation  of  pain  and  the 
restoration  of  their  expulsive  quality  to  the  uterine  contractions.  No 
plan  of  action  should  be  decided  upon  without  first  carefully  investi- 
gating the  cause  of  delay.  The  suspensive  influence  of  a  full  bladder 
or  rectum  is  always  to  be  borne  in  mind.  In  face,  breech,  and  shoul- 
der presentations,  and  in  contracted  pelves,  the  slow  dilatation  of  the 
cervix  is  the  rule,  and,  with  such  exceptions  as  will  be  noted  in  their 
appropriate  connections,  do  not  call  for  interference.  A  faulty  posi- 
tion of  the  uterus  should,  if  possible,  be  rectified  by  suitable  abdom- 
inal support.  Adhesions  of  the  membranes  to  the  lower  uterine 
segment  should  be  dissected  up  by  the  index-finger.    In  hydramnion, 

*  Lahs,  "  Die  Theorie  der  Geburt,"  pp.  285  et  seq. 

\  Breisky,  "  Ucber  die  Behandlung  der  puerperalen  Blutungen,"  Volkmann's  "  Samml. 
klin.  Vortr.,"  No.  14,  p.  92. 


424 


THE  PATHOLOGY  OF  LABOR. 


rupture  of  the  membranes,  so  as  to  allow  the  partial  escape  of  the 
amniotic  fluid,  is  sometimes  serviceable. 

If  the  length  of  the  labor  is  simply  due  to  the  insufficient  uterine 
action,  the  conduct  of  the  accoucheur  will,  in  a  measure,  depend  upon 
the  frequency  and  severity  of  the  pains  and  the  endurance  of  the 
patient.  If  the  pains  occur  at  such  intervals,  and  with  such  mildness 
that  the  patient  is  able  to  eat,  to  sleep,  and  to  attend  to  ordinary 
household  duties,  the  dilatory  progress  of  labor  should  cause  no  appre- 
hension. In  pathological  conditions  it  is  the  element  of  pain  which 
is  most  to  be  dreaded.  Pain  long  continued  is  a  powerful  nerve-de- 
pressant. When  combined  with  starvation  and  deprivation  of  sleep, 
it  greatly  impairs  a  woman's  capacity  to  resist  the  perils  of  the  puer- 
peral period.  While,  therefore,  the  indication  for  treatment  is  clear 
enough,  it  is  not  so  easy  in  a  given  case  to  decide  whether  the  remedy 
should  be  applied  first  to  the  relief  of  pain,  or  whether  efforts  should 
be  directed  at  once  to  the  acceleration  of  labor,  so  as  most  speedily  to 
place  the  patient  beyond  the  hazards  of  parturition.  As  a  rule,  how- 
ever, it  may  be  stated  that  anodynes  are  appropriate  in  cases  where  the 
cervix  is  but  slightly  dilated,  while  accelerative  measures  naturally  re- 
ceive the  preference  in  those  where  the  first  stage  of  labor  is  already 
far  advanced. 

The  pain-stilling  agents  from  which  the  selection  should  be  made 
are  the  warm  bath,  chloroform,  chloral  by  rectal  injection,  and  mor- 
phia, either  alone  or  combined  with  minute  doses  of  atropia.  In  prac- 
tice it  will  usually  be  found  convenient  to  begin  with  chloroform,  and 
then  to  sustain  its  action  by  the  hypodermic  injection  of  morphia, 
suspending  the  chloroform  so  soon  as  the  tranquillizing  effect  of  the 
latter  is  developed.  Opiates  often  accomplish  wonders  in  one  of  two 
ways  :  when,  owing  to  the  prolongation  of  the  labor  and  its  attend- 
ant pain,  the  patient's  nervous  energies  have  become  exhausted,  the 
arrest  of  pain  enables  the  woman  to  sleep,  and,  with  the  recuperation 
of  power  that  comes  upon  awakening,  good  pains  follow,  which  bring 
the  labor  to  a  happy  termination.  In  other  cases,  after  the  employ- 
ment of  the  anodyne  the  parts  apparently  relax,  and  an  acceleration 
of  labor  follows.  In  these  cases  the  oxytocic  effect  is  probably  due 
to  the  quieting  action  exerted  upon  the  spinal  nerves.  It  has  been 
surmised  that  the  nerves  of  the  uterus  derived  from  the  cerebro- 
spinal system  possess  inhibitory  properties — a  theory  which,  if  true, 
readily  explains  how  severe  pain  suspends  uterine  action,  and  how  the 
quieting  of  pain  would  restore  to  the  motor  nerves  their  full  energy. 

In  a  certain  proportion  of  cases  the  effects  of  the  anodyne  or  an- 
aesthetic are  of  but  short  duration.  In  from  ten  to  thirty  minutes  the 
acute  suffering  returns,  and  the  short  truce  is  unattended  with  benefit. 
There  is  an  erroneous  opinion  that,  so  long  as  the  membranes  are  un- 
ruptured, this  condition  may  be  allowed  to  go  on  indefinitely.    It  is, 


ANOMALIES  OF  THE  EXPELLENT  FORCES. 


425 


however,  of  the  greatest  importance  that  the  length  of  the  period  of 
non-interference  should  be  governed  by  the  strength  of  the  patient. 
There  is  nothing  that  requires  more  judgment  in  midwifery  practice 
than  to  decide  when  the  time  has  arrived  at  which  delay  is  fraught 
with  more  danger  than  active  interference.  For  my  own  part,  I  be- 
lieve that  many  fair  lives  are  needlessly  squandered  because  of  excessive 
timidity  begotten  of  imperfect  obstetric  teachings. 

If  pain-stilling  agents  do  no  good,  or  if  the  first  stage  is  already 
far  advanced,  the  physician  should  seek,  by  restoring  to  the  pains  their 
expulsive  character,  to  hasten  delivery. 

Of  reputed  service  in  cases  of  uterine  insufficiency  are  the  warm 
vaginal  douche,  the  dilating  bags  of  Barnes,  the  introduction  of  a 
bougie  into  the  uterus,  forceps,  and  the  internal  administration  of 
quinine,  ergot,  viscum  album,  borax,  cannabis  Indica,  cinnamon,  or 
digitalis. 

The  bougie  is  applicable  only  to  cases  where  the  membranes  are 
intact,  and  where  the  pains  are  weak  without  being  cramp-like  in  char- 
acter. In  hospital  practice  it  possesses  the  disadvantage  that  it  can 
become  the  conveyer  of  infection  to  the  uterine  cavity. 

The  vaginal  douche  possesses  a  wider  range  of  utility.  It  is  safe 
and  tolerably  effective,  under  favorable  conditions.  It  promotes  the 
organic  changes  in  the  cervix,  stimulates  the  uterus  to  contract,  and 
mechanically  distends  the  vagina.  Its  action  is,  however,  apt  to  be 
slow  and  somewhat  uncertain.  In  a  case  of  over-distention  of  the 
amnion,  I  once  saw  its  employment  followed  immediately  by  complete 
tonic  rigidity  of  the  uterine  muscular  fibers. 

Of  all  the  resources  at  our  disposal,  however,  the  water-bags  of  Dr. 
Barnes  stand  easily  at  the  head.  Passed  within  the  cervix,  and  dis- 
tended so  as  to  place  the  canal  moderately  upon  the  stretch,  they  not 
only  serve  to  mechanically  dilate  the  os,  but  are  most  efficient  as  reflex 
exciters  of  the  labor-pains.  If  left  in  situ  until  expelled  into  the  vagi- 
na by  the  bearing-down  efforts  they  awaken,  the  cervix  will  be  found 
to  have  lost  its  rigidity.  If  necessary,  a  larger  dilating  bag  should 
then  be  employed  in  the  same  way.  An  attempt  to  dilate  the  cervix 
rapidly  and  with  violence  is  neither  safe  nor  profitable.  To  obtain 
permanent  results  it  is  essential  to  effect  the  organic  changes  in  the 
tissues  which  render  them  physiologically  dilatable.  In  cases  of  tonic 
rigidity  of  the  uterus,  the  production  of  normal  pains  will  sometimes 
be  assisted  by  rupturing  the  membranes  and  raising  the  head,  so  as  to 
allow  a  small  portion  of  the  amniotic  fluid  to  escape,  previous  to  resort- 
ing to  the  Barnes  water-bags. 

When,  after  rupture  of  the  membranes,  a  segment  of  the  head 
presents  at  the  os  externum,  the  rubber  bags  are  of  less  service.  In 
such  cases  often  we  are  able  to  accomplish  speedy  dilatation  by  simply 
asking  the  woman  to  hold  her  breath,  and  to  reenforce  the  uterine 


426 


THE  PATHOLOGY  OF  LABOR. 


pains  by  the  action  of  the  auxiliary  muscles.  If  this  plan  fails,  forceps 
should  be  applied,  and  the  head  be  made  to  serve  as  the  dilating  body. 
To  avoid  lacerating  the  cervix,  the  tractions  should  be  intermittent, 
and  should  be  suspended  during  the  acme  of  the  pains.  The  rule 
given  for  the  preservation  of  the  perinseum  will  be  found  most  service- 
able in  attempts  to  maintain  the  integrity  of  the  cervix,  viz.,  that  the 
extraction  is  most  safely  accomplished  during  the  period  of  greatest 
relaxation,  and  not  at  the  moment  of  extreme  tension.* 

Of  the  various  internal  remedies  to  stimulate  uterine  action,  ergot 
should,  in  the  first  stage  of  labor,  be  unqualifiedly  prohibited.  In 
spite  of  numerous  favorable  experiences  from  its  use,  its  tendency  to 
intensify  tonic  contraction  of  the  involuntary  muscular  fibers  makes  it 
always  a  perilous  drug.  The  enthusiastic  praises  of  quinine  by  Drs. 
Fordyce  Barker  and  Albert  H.  Smith,  of  Philadelphia,  warrant  fur- 
ther trials  of  its  efficacy.  Dr.  Smith  says  :  ^*I  do  not  hesitate  to  give 
it  in  every  case,  because,  even  where  there  is  no  decided  inertia  at  the 
onset  of  labor,  there  may  be  failure  of  the  powers  of  the  mother  from 
early  exhaustion  and  fatigue,  and  we  get  the  benefit  of  the  quinia  in 
diminishing  this  tendency  and  also  in  promoting  the  condensation  of 
the  uterine  fiber  after  the  delivery  of  the  placenta,  thus  lessening  the 
dangers  of  post-partum  haemorrhage  and  the  annoyances  of  the  after- 
pains  so  commonly  resulting  from  a  slow  condensation  of  the  uterine 
muscle."  f  He  recommends  the  bisulphate  in  a  fifteen-grain  dose, 
which  he  declares  acts  altogether  beneficially  as  a  stimulant  to  the 
normal  uterus.  The  other  agents  mentioned  as  possessing  direct  or 
incidental  ecbolic  properties  are  now  chiefly  of  historic  interest. 

Irregular  Pains  in  the  Second  Stage  of  Lahor. — In  many  cases  the 
pains  maintain  their  normal  quality  until  the  completion  of  the  first 
stage  of  labor,  and  the  descent  of  the  head  to  the  floor  of  the  pelvis. 
When  in  the  second  stage  of  labor  the  pains  become  inefficient  and 
lose  their  expulsive  character,  the  non-advance  of  the  head  is  usually 
attributed  to  a  rigid  perinseum.  But  it  is  a  matter  of  every-day  expe- 
rience that  with  really  good  pains  and  normal  head  mechanism  the 
perinaeum  speedily  loses  its  rigidity.  Of  course,  it  is  not  denied 
that,  in  primiparae,  the  organic  changes  which  effect  the  softening  of 
the  perinseum  need  for  their  accomplishment  relatively  stronger  pains 
than  in  multiparae.  The  faulty  action  of  the  expellent  forces  in  the 
second  stage  is  due  either  to  exhausted  nerve-power  or  to  excessive 
uterine  retraction.  In  the  former  case,  labor  becomes  powerless  from 
the  feeble  character  of  the  pains  ;  in  the  latter,  it  results  from  the 
withdrawal  upward  of  the  uterine  muscle,  and  the  consequent  les- 

*  I  have  purposely  avoided  making  mention  of  incisions  through  the  vaginal  portion 
of  the  cervix,  as,  in  a  large  experience  in  difficult  labors,  I  have  never  so  far  seen  the 
occasion  for  their  employment. 

f  Albert  II.  Smith,  "  Retarded  Dilatation  of  the  Os  Uteri  in  Labor,"  p.  2*7. 


ANOMALIES  OF  THE  EXPELLEXT  FORCES. 


427 


sening  of  the  intra-iiterine  pressure.  These  cases  of  retraction  are 
worthy  of  special  consideration.  Thus^  Hof meier  *  found  in  a  num- 
ber of  instances,  where  the  head  rested  on  the  pelvic  floor,  that  the 
ring  of  Bandl,  which  was  made  out  by  palpation  through  the  abdomi- 
nal walls,  w^as  situated  at  from  five  to  seven  inches  above  the  symphy- 
sis pubis,  so  that  the  contractile  portion  of  the  uterus  covered  not  more 
than  one  third  of  the  foetus.  Under  such  circumstances,  while  the 
patient  suffers  from  intense  pain,  the  contractions  of  the  partially 
emptied  uterus  do  not  possess  the  force  to  overcome  the  resistance  of 
a  rigid  perinaeum. 

Treatment. — In  all  cases  of  protracted  second  stage,  before  deciding 
upon  the  existence  of  uterine  irregularity,  both  the  bladder  and  the 
bowels  should  be  emptied,  and  care  should  be  taken  to  exclude  the 
existence  of  obstruction  from  the  bony  pelvis.  If  the  only  resistance 
to  be  overcome  is  that  furnished  by  the  soft  parts,  weak  pains  should 
be  reenforced  by  the  action  of  the  abdominal  muscles.  After  rotation 
of  the  head  is  completed,  a  new  vis  a  tergo  may  be  supplied  by  press- 
ure applied  to  the  breech  through  the  abdominal  walls  after  the 
method  of  Kristeller,  or  by  the  modified  form  of  expression  recom- 
mended by  Bidder,  t  According  to  the  latter,  the  physician  should 
stand  to  the  left  of  his  patient,  and  grasp  the  breech  of  the  foetus  with 
the  right  hand  ;  he  should  then  raise  the  breech  and  fix  it  in  such  a 
position  that  the  pressure  applied  will  be  best  transmitted  through  the 
spinal  column  to  the  cephalic  end — a  point  to  be  determined  by  the 
fingers  of  the  left  hand,  which  should  likewise  control  the  movements 
of  the  head  during  the  period  of  expulsion.  The  force,  the  frequency, 
and  the  length  of  the  acts  of  expression  should  of  course  be  decided  by 
the  judgment  and  experience  of  the  operator. 

Where  the  movements  of  flexion  and  rotation  have  been  imperfectly 
performed,  little  is  to  be  expected  from  any  of  the  forms  of  expression. 
The  available  remedies  are  then  ergot  and  the  forceps.  Of  these  the 
advantages  of  safety  and  celerity  are  all  on  the  side  of  the  forceps. 
Many  practitioners,  however,  who  have  observed  that  in  practice  ergot 
often  acts  likewise  with  speed  and  safety,  accord  to  it  a  large  measure 
of  confidence.  But  along  with  these  more  fortunate  experiences  there 
is  a  shady  aspect  to  be  remembered.  When  the  tardy  labor  is  due  to 
tonic  retraction,  the  use  of  ergot  is  calculated  to  aggravate  the  sources 
of  delay.  In  other  cases  tonic  retraction  is  the  direct  result  of  ergo  tic 
action,  and,  as  a  consequence  of  restricted  utero-placental  circulation, 
the  life  of  the  foetus  is  jeopardized.  When,  therefore,  the  drug  is 
used,  the  heart-sounds  of  the  foetus  should  be  carefully  watched,  and, 

*  HoFMEiER,  "  Ueber  Contractionsverhaltnisse  des  kreissenden  Uterus,"  "  Ztschr.  f . 
Geburtsh.  u.  Gynaek.,"  Bd.  vi,  p.  164. 

f  E.  Bidder,  "Zur  Beurtheilung  der  Kristeller'schen  Expressionsmethode  bei  Kopf- 
lagen,"  "  Ztschr.  f.  Geburtsh.  u.  Gynaek.,"  Bd.  iii,  p.  241, 


428 


THE  PATHOLOGY  OF  LABOR. 


with  the  first  signs  of  failing  force,  the  forceps  should  be  applied  to 
rescue  the  child  from  the  impending  danger  of  asphyxia. 

Note  on  the  Use  of  Ergot  in  Partueition. — Secale  cornutum,  or  ergot,  the 
active  principle  of  which  is  ergotin,  according  to  Buchheim,*  and  ergotic  acid, 
according  to  Zweifel,t  is  universally  acknowledged  to  increase  the  frequency, 
length,  and  power  of  the  uterine  contractions  during  parturition,  and  to  finally 
induce  a  tetanic  condition  of  the  uterine  muscular  fibers.  Its  action  upon  the 
unimpregnated  uterus  is  the  same  in  kind,  but  less  marked  in  degree,  and  of  less 
constant  occurrence.  The  views  of  high  authorities  in  regard  to  the  manner  in 
which  these  effects  are  produced  present  irreconcilable  difterences.  Wernich  X 
attributes  the  ecbolic  properties  of  ergot  to  irritation  of  the  uterine  nervous  cen- 
ters, induced  by  arterial  anaemia  of  the  spinal  cord  and  of  the  uterine  tissues. 
This  anaemia  is  referred  by  him  to  loss  of  tone  in  and  dilatation  of  the  veins, 
whereby  venous  congestion,  leading  to  secondary  arterial  anaemia,  is  produced.* 
Other  observers  assume  a  primary  contraction  of  the  capillaries,  with  a  consequent 
Increased  arterial  pressure,  as  the  source  of  the  anaemic  irritation  of  the  nerve- 
centers,  while  still  others  believe  direct  stimulation  of  the  uterine  muscular 
fibers,  by  the  ergot,  to  be  the  cause  of  their  exaggerated  contractility.! 

Kohler  refers  the  uterine  contractions  produced  by  ergot  to  increased  irrita- 
bility of  the  peripheral  nerves,  in  conjunction  with  anaemia  of  the  spinal  cord.^ 
These  conflicting  views  pertain  chiefly  to  points  of  purely  theoretical  interest, 
and  need  not  prevent  the  obstetrician  from  obtaining  a  clear  conception  of  his 
duty  in  the  practical  administration  of  ergot.  The  above-mentioned  incontro- 
vertible facts  concerning  its  operation  suffice  to  guide  the  physician  in  the  em- 
ployment of  this  useful  drug,  even  if  he  be  unable  at  present  to  definitively  de- 
cide regarding  the  exact  mechanism  of  its  physiological  action. 

Ergot  should  never  be  exhibited  during  the  first  stage  of  labor,  because  the 
tetanic  uterine  contractions,  which  it  substitutes  for  the  normal  rhythmical  ones, 
tend  to  prevent  the  further  dilatation  of  the  os  uteri  and  to  deprive  the  foetus 
of  its  blood-supply  through  the  constriction  of  the  uterine  vessels.  Should  the 
membranes  have  ruptured  before  the  termination  of  the  first  stage,  the  adminis- 
tration of  ergot  would  endanger  the  life  of  the  foetus  by  causing  undue  pressure 
to  be  exerted  upon  the  umbilical  cord.  We  should  also  abstain  from  the  use  of 
ergot  during  the  second  stage,  unless  it  seem  necessary  as  a  prophylactic  against 
jjost-partum  hjemorrhage.  Even  under  these  circumstances  it  should  never  be 
administered  if  there  be  the  slightest  mechanical  obstacle  to  delivery,  or  if  the 
fetal  head  be  high  up  in  the  pelvic  canal.  Spiegelberg^  insists  upon  the  neces- 
sity of  carefully  observing  the  fetal  heart  after  the  use  of  ergot,  in  order  that 
instrumental  delivery  may,  in  case  of  threatened  asphyxia,  be  promptly  resorted 
to.  Benicke  records  twenty-seven  cases  in  which  ergot  was  administered  dui-ing 
the  second  stage  on  account  of  inertia  uteri.    Spontaneous  delivery  occurred  in 

*  Buchheim,  Schmidt's  "  Jahrb.,"  vol.  clxiv,  p.  12. 

f  ZwEiFEL,  '*  Ucb.  d.  Secale  corn.,"  "  Arch.  f.  exp.  Pathol.,"  vol.  iv,  1875,  p.  407. 
X  Wernich,  "Einigc  Vevsuch.  iib.  d.  Mutterk.,"  "Beitrag.  z.  Geburtsh.,"  vol.  ill,  1874, 
p.  102. 

*  Wernich,  op.  ciL,  p.  91. 

II  Benicke,  "Ueb.  Anwend.  d.  Mutterk.  in  d.  Geburtsh.,"  "Ztschr.  f.  Geburtsh.  u. 
Gynaek.,"  vol.  iii,  1878,  p.  174. 

^  Kohler,  Schmidt's  "Jahrb.,"  vol.  clxiv,  p.  14.      ^  Spiegelberg,  "  Lchrb.,"  p.  414. 


ANOMALIES  OF  THE  EXPELLENT  FORCES. 


429 


only  seven  of  these  cases.*  Ergot  is  not  specially  adapted  to  the  arrest  of 
haemorrhage  accompanying  abortion  or  premature  delivery.  In  these  cases,  and 
in  haemorrhage  caused  by  retained  shreds  of  the  fetal  envelopes,  the  appropriate 
treatment  consists  in  the  tampon  and  in  subsequent  complete  evacuation  of  the 
uterine  cavity.  The  only  imperative  exhibition  of  ergot  is  presented  by  the 
occurrence  oi  post-par  turn  haemorrhage  resulting  from  uterine  atony. t  The  im- 
yielding,  tetanic  uterine  contractions  which  it  produces  act  most  beneficently  by 
occluding  the  orifices  of  the  bleeding  vessels.  Even  under  these  circumstances 
it  should,  however,  be  withheld  until  after  the  expulsion  of  the  placenta,  lest 
the  uniform  uterine  contractions  lead  to  its  prolonged  retention  or  interfere  with 
manual  efforts  for  its  extraction. 

Irregular  Pains  in  the  Third  Stage  of  Labor. — The  tardy  expulsion 
of  the  placenta,  due  to  atony  of  the  uterus,  is  of  rare  occurrence  when 
the  Crede  method  of  expression  is  uniformly  practiced.  As,  in  relaxed 
conditions  of  the  uterus,  blood  pours  from  the  patulous  mouths  of  the 
torn  utero-placental  vessels  into  the  fundus,  a  free  external  discharge 
of  blood  follows  of  necessity  whenever  contractions  are  excited — a  fact 
to  be  borne  in  mind  by  an  unpracticed  obstetrician,  lest  he  mistake 
the  simple  conversion  of  an  internal  into  an  external  haemorrhage  for 
one  produced  by  the  manipulations  which  have  been  recommended. 
The  w^hole  subject  of  atony  in  the  third  stage  is,  however,  so  closely 
associated  with  the  occurrence  of  post-partum  haemorrhage  that  its 
specific  consideration  will  be  reserved  for  separate  study  in  connec- 
tion with  the  haemorrhages  which  take  place  during  and  subsequent 
to  labor. 

After  the  birth  of  the  child,  retraction  of  the  uterus  is  Nature's 
safeguard  against  haemorrhage.  As  a  result  of  the  abuse  of  ergot,  or, 
in  other  cases,  from  an  abnormal  adherence  of  the  placenta,  such  an 
extreme  degree  of  retraction  may  be  reached  before  the  completion  of 
the  third  stage  as  to  lead  to  the  imprisonment  of  the  placenta  within 
the  uterine  cayity.  In  these  cases,  complete  retraction  in  the  body  of 
the  uterus  is  prevented  by  the  presence  of  the  placental  mass.  Below 
the  latter,  where  no  obstacle  is  opposed  to  the  shortening  of  the  mus- 
cular fibers,  a  constriction  results.  The  stricture  is  most  pronounced 
at  the  ring  of  Bandl.  The  lower  uterine  segment  and  the  cervix 
proper  are  usually  in  a  sub-paralytic  condition,  and  widen  from  above 
downward  to  the  vaginal  insertion.  From  the  shape  thus  imparted  to 
the  uterus,  this  condition  is  generally  known  as  an  hour-glass  con- 
traction." When  met  with  for  the  first  time,  it  is  apt  to  prove  ex- 
tremely puzzling.  In  following  the  cord  upward,  its  continuation 
through  the  stricture  is  sometimes  overlooked.  In  several  cases  I 
have  known  the  pulpy  mucous  membrane  of  the  lower  segment  to  be 
mistaken  for  an  adherent  placenta,  and  have  been,  in  consequence, 
summoned  to  assist  in  its  removal. 


*  Benicke,  op.  cit.^  p.  ITS, 


f  SCHROEDER,  "  Lehrb.,"  fifth  edition,  p.  4Y1. 


430 


THE  PATHOLOGY  OF  LABOR. 


Treatment. — By  patient  waiting,  relaxation  of  the  stricture  usually 
takes  place  sjyontaneously.  The  result  may  be  promoted  by  the  hypo- 
dermic injection  of  morphia,  combined  with  atropia.  It  is  not,  how- 
ever, altogether  safe  to  leave  the  patient  before  the  expulsion  of  the 
placenta  has  taken  place ;  for,  exceptionally,  the  muscular  fibers  of 
the  body  of  the  uterus  may  relax  prior  to  those  of  the  lower  segment, 
and  thus  haemorrhage  may  result.  Injections  of  ice-cold  water  were 
recommended  in  such  cases  by  Seyfert,  as  tending  not  only  to  restrain 
haemorrhage,  but  to  promote  regular  expulsive  uterine  action.  Forci- 
ble dilatation  is  rarely  necessary,  and  should  be  reserved  for  haemor- 
rhages of  an  alarming  character.  In  nearly  all  cases,  however,  it  is 
practicable,  even  in  extreme  examples,  to  extract  the  placenta  in  a 
short  time  without  force  or  violence.  The  plan  I  have  followed  of 
late  years,  with  uniform  success,  consists  in  introducing  the  index  and 
middle  fingers,  with  the  whole  hand  in  the  vagina,  to  the  point  of 
constriction.  Then,  by  pressing  the  uterus  downward,  the  fin- 
gers are  brought  in  contact  with  the  placental  border.  Now,  it  is 
only  necessary  to  draw  a  single  cotyledon  into  the  canal  to  render 
the  further  extraction  a  matter  of  certainty.  Under  the  pressure  of 
the  soft  placental  mass  the  stricture  relaxes  slowly.  By  combining 
expression  with  slight  traction,  the  delivery  is  surely  accomplished. 
The  principal  difficulty  of  the  operation  lies  in  the  manipulations 
needful  to  bring  the  placenta  at  the  outset  to  the  point  of  strict- 
ure, but  this  difficulty  can  be  pretty  certainly  overcome  by  patience 
and  the  determination  to  succeed.  During  the  period  of  with- 
drawal, the  operator  should  be  content  with  a  very  slow  progres- 
sion, proportioned  to  the  yielding  of  the  tissues  ;  otherwise  the  pre- 
senting portion  of  the  placenta  tears  away,  when  the  labor  expended 
is  lost. 

Painful  Labors. — In  nearly  all  forms  of  abnormal  uterine  contrac- 
tions the  pain  of  labor  reaches  a  pathological  degree  of  intensity. 
Especially  we  have  had  occasion  to  call  attention  to  the  intolerable 
suffering  in  cases  of  long-continued  reciprocal  pressure  between  the 
uterus  and  its  contents. 

But  acute  suffering  sometimes  attends  upon  the  preliminary  stages 
of  labor.  During  the  latter  days  of  pregnancy  in  primiparae,  often  for 
a  few  hours  only  preceding  the  advent  of  true  labor-pains  in  multi- 
parae,  contractions  occur  which  normally  scarcely  attract  the  atten- 
tion of  the  patient.  In  rare  instances,  however,  the  suffering  they 
occasion  is  extreme.  In  hysterical  women  these  preliminary  pains  are 
often  of  an  agonizing  character,  rendering  it  necessary  to  resort  for 
their  relief  to  such  palliations  as  the  warm  bath,  opium,  and  chloro- 
form. 

But,  even  where  hysteria  does  not  exist  as  a  cause,  the  pains  may 
be  so  severe,  while  the  cervix  has  still  its  normal  length,  that  the 


ANOMALIES  OF  THE  EXPELLENT  FORCES. 


431 


woman  believes  herself  in  labor,  and,  indeed,  the  contractions  are  as 
painful  as  in  actual  labor.  There  are  no  febrile  symptoms  indicative 
of  inflammation  either  of  the  uterus  or  of  its  appendages.  The  pain  is 
like  that  in  muscular  rheumatism.  Though  the  term  rheumatism  of 
the  uterus  is  often  applied  to  this  condition,  its  pathology  is  uncer- 
tain. It  is  very  probable  that  practitioners  confound  together,  under 
the  foregoing  title,  a  number  of  distinct  affections,  such  as  hysterical 
hyperaesthesia,  intestinal  irritability,  and  the  early  stages  of  inflamma- 
tion. Excluding  these  morbid  conditions,  there  remains  a  class  of 
cases  practically  important  from  the  disappearance  of  the  pain  upon 
the  induction  of  intense  diaphoresis.  Patients,  who  for  days  have  been 
treated  with  hypodermic  injections  of  morphia,  with  only  moderate 
results,  are  often  relieved  as  if  by  magic  by  placing  them  in  a  warm 
bath,  and  then  covering  them  with  blankets,  giving  in  addition  hot 
drinks  and  Dover's  powder,  until  they  become  bathed  in  abundant 
perspiration. 

It  is  often  difficult,  toward  the  close  of  pregnancy,  to  distinguish 
between  colic-pains  due  to  fecal  accumulation,  or  the  presence  of  gases 
in  the  stomach  and  intestines,  troubles  to  which  pregnant  women  are 
especially  disposed,  and  uterine  contractions  of  a  painful  character. 
Indeed,  in  the  former  case  the  uterus  becomes  involved  to  some  ex- 
tent, so  that  the  cervix  is  felt  during  a  cramp  to  simultaneously 
harden.  Moreover,  after  labor  has  actually  begun,  it  may  become 
complicated  by  colic-pains,  which  exercise  in  turn  a  suspensive  influ- 
ence upon  parturition.  But  the  colic-pains  are  themselves  inter- 
mittent, and  are,  therefore,  liable  to  be  mistaken  for  those  of  labor. 
Thus  it  is  possible  to  become  involved  in  perplexities  which  time 
alone  can  solve.  Even  when  we  have  made  out  the  diagnosis  of 
"false  labor,"  and  give  an  opiate  for  the  relief  of  the  patient,  it  may 
happen  that  the  first  result  of  quieting  the  pain  may  be  the  accelera- 
tion of  labor.  When  this  does  not  occur,  we  should  guard  against  the 
return  of  the  trouble  by  clearing  out  the  bowels  by  purgatives  or 
enemata. 

In  normal  labors,  the  pulse  becomes  more  rapid  at  the  beginning 
of  each  pain,  and  continues  to  increase  in  frequency  until  the  pain  has 
reached  its  acme,  after  which  a  gradual  declination  follows.  But 
sometimes  labor  is  attended  by  marked  febrile  symptoms.  There  exist 
rapidity  of  the  pulse  between  the  pains  and  a  continuous  elevation  of 
temperature.  Now,  if,  at  the  same  time,  the  uterine  contractions  are 
the  source  of  extraordinary  suffering,  there  is  strong  reason  for  sus- 
pecting that  labor  is  complicated  by  inflammatory  conditions  of  the 
organs  concerned  in  parturition.  Thus,  a  latent  pelvi-peritonitis  may 
be  converted  into  the  acute  form  by  the  several  acts  which  comprise 
normal  labor,  or  the  prolonged  tonic  contraction  of  the  uterus  upon 
the  foetus  after  the  rupture  of  the  membranes,  especially  in  neglected 


432 


THE  PATHOLOGY  OF  LABOR. 


shoulder  presentations  and  in  contracted  pelves,  may  giye  rise  to  inflam- 
matory affections  in  the  nterus  itself.  In  either  case  the  coexistence 
of  intense  pain  with  febrile  symptoms  should  awaken  serious  appre- 
hensions. Especially  ought  we  to  be  upon  our  guard  against  the 
treacherous  lull  in  the  symptoms  that,  as  a  rule,  takes  place  when 
labor  is  at  an  end.  After  a  day  or  two  we  may  expect  a  chill  and  the 
return  of  the  fever.  In  the  early  stages  of  metritic  and  perimetritic 
trouble,  a  ten-grain  dose  of  calomel  often  exercises  a  beneficent  action 
in  arresting  the  disease.  Where  labor  has  so  far  advanced  that  the 
induction  of  artificial  diarrhoea  is  rendered  impracticable,  opiates, 
though  of  inferior  value,  soothe  the  pain,  and  are  our  next  most  valu- 
able resource. 


CHAPTEE  XXV. 

CONTRACTED  PEL  VES. 

Varieties. — Frequency. — Diagnosis. — Pelvic  measurements. — Forms  of  the  contracted  pel- 
vis.— Justo-minor  pelves. — Flattened  non-rachitic  pelves. — Rachitic  flattened  pelves. 
— Generally  contracted,  flattened  pelves. — Irregular  forms. — Pseudo-osteomalacia. 
— Scoliosis. — Kyphosis. — Influence  of  contracted  pelves  during  pregnancy  and  labor. 
— Influence  upon  the  uterus. — Influence  upon  the  presentation. — Influence  upon  the 
pains. — Influence  upon  the  first  stage  of  labor. — Influence  upon  the  mechanism  of 
labor. — Effects  of  pressure  upon  the  maternal  tissues. — Influence  upon  the  fetal 
head. — Effects  of  pressure  upon  the  integuments  ;  upon  the  cranium. — Prognosis. 

Ik  contracted  pelves  sometimes  a  single  diameter,  sometimes  all 
the  principal  diameters  are  reduced  below  the  normal  average.  The 
relative  proportion  of  the  parts  may  be  to  a  considerable  extent  pre- 
served, or  the  pelvis  may  have  been  distorted  by  special  morbid  condi- 
tions, giving  rise  to  unequal  development  and  changes  of  outline. 
These  peculiarities  embarrass  all  attempts  at  classification.  Still,  the 
study  of  the  subject  is  greatly  simplified  by  the  fact  that  the  dimin- 
ished space  is,  in  the  great  proportion  of  cases,  located  chiefly  at  the 
brim.  Aside  from  these,  there  remain  a  variety  of  irregular  forms  of 
rare  occurrence,  each  requiring  a  separate  description  and  plan  of 
treatment. 

It  is  to  those  cases  in  which  the  narrowing  is  chiefly  at  the  brim 
that  the  term  contracted  pelves"  is  generally  applied.  The  other 
forms  are  all  specially  designated  by  some  qualifying  adjective  defin- 
ing their  character. 

Contracted  pelves  proper  are  divided  into — 

1.  The  pelvis  aequabiliter  justo-minor,  in  which  all  the  diameters, 
from  the  brim  to  the  outlet,  are  diminished  in  very  nearly  equal 
measure. 


CONTRACTED  PELVES. 


433 


2.  The  flattened  pelvis,  contracted  specially  in  the  conjugate  diam- 
eter. In  this  form,  the  transverse  diameter  may  be  normal,  or  may 
be  diminished.    Thus,  we  distinguish — 

a.  Simple  flattened  pelves  (transverse  diameter  normal). 

b.  Flattened,  generally  contracted  pelves  (narrowing  in  the  trans- 
verse as  well  as  the  conjugate  diameter). 

As  it  is  rare  to  find  two  pelves  possessing  the  same  measurements, 
the  question  arises  as  to  the  degree  of  antero-posterior  shortening 
which  suffices  to  distinguish  the  contracted  from  the  normal  pelvis. 

It  is  often  customary  to  consider  the  contracted  pelvis  simply  as 
furnishing  a  mechanical  obstacle  to  the  passage  of  the  child's  head, 
but  this  is  to  overlook  a  great  variety  of  very  important  modifications 
to  which  it  gives  rise  during  pregnancy  and  labor.  These  remoter  in- 
fluences are  often  observable  in  cases  where  labor,  if  considered  from 
the  standpoint  of  length  alone,  would  be  regarded  as  normal. 

Michaelis  *  and  Litzniann,f  whose  investigations  furnish  the  basis 
of  modern  opinion  regarding  the  contracted  pelvis,  place  the  limit  at 
three  and  a  half  inches  for  the  simple  flattened  pelvis,  and  at  four 
inches  for  those  likewise  diminished  in  the  transverse  diameter.  Yet 
even  above  these  limits  the  action  of  the  narrow  pelvis  is  not  rarely 
manifested  in  disturbance  of  the  normal  mechanism  of  labor. 

In  Germany,  Litzmann,  Michaelis,  Spiegelberg,  and  Schroeder  I 
place  the  average  frequency  of  contracted  pelves  at  fourteen  per  cent., 
and  in  my  own  field  of  experience,  in  the  Emergency  and  Maternity 
Hospitals  of  New  York  City,  the  inmates  of  which  are,  however,  almost 
entirely  of  foreign  birth,  every  variety  and  degree  of  pelvic  deformity 
finds  abundant  illustration.  In  our  native  American  women  abnormal 
pelves  are  rare.  I  frequently  hear  from  country  physicians,  who  attend 
lectures  at  the  Bellevue  Hospital  Medical  College,  that,  in  long  years 
of  practice,  they  have  never  met  with  a  single  instance.  Yet  it  is  im- 
possible to  study  the  cases  of  vesico- vaginal  fistulae  reported  by  Dr. 
T.  A.  Emmet  *  without  arriving  at  the  conclusion  that  the  existence 
of  contracted  pelves  is  frequently  overlooked.  Certainly  the  immu- 
nity of  American  women  is  by  no  means  so  absolute  as  to  justify  the 
neglect  into  which  the  study  of  pelvic  deformity  has  so  generally 
fallen. 

The  Diagnosis  of  Contracted  Pelvis. — The  diagnosis  of  pelvic 
deformity  is  based  upon  direct  examination.  Certain  facts  in  the 
previous  history  of  the  patient  are  often  of  substantial  value  in  the 
way  of  confirmatory  evidence,  or  by  directing  attention  to  the  prob- 
able existence  of  deformity. 

*  Michaelis,  "Das  enge  Becken,"  Leipsic,  1865. 

f  Litzmann,  "Die  Formen  des  Beckcns,"  Berlin,  1861. 
X  Spiegelbero,  "Lchrbuch,"  18*78,  Bd.  ii,  p.  426. 

*  Emmet,  "  Vesico- Vaginal  Fistula,"  William  Wood,  1868. 
28 


434 


THE  PATHOLOGY  OF  LABOR. 


Previous  History. — Inquiry  should  be  instituted  regarding  the  oc- 
currence of  rickets  in  early  childhood,  and  especially  in  this  connection 
as  to  the  period  of  the  appearance  of  the  teeth.  Late  dentition  is  an 
ordinary  sign  of  imperfect  bone  formation.  A  cross  baby,  bottle-fed, 
or  improperly  nursed,  suffering  from  repeated  attacks  of  indigestion, 
from  restlessness  at  night,  and  profuse  perspirations,  who  cuts  the 
first  incisor  teeth  in  the  second  year,  has  presumptively  had  rickets. 
A  history  of  this  nature,  even  in  the  absence  of  the  grosser  evidences 
of  rickets,  such  as  the  square  head,  the  pigeon-breast,  the  tumefied 
abdomen,  small  stature,  spinal  curvature,  enlarged  joints,  and  incur- 
vation of  the  long  bones  of  the  extremities,  is  to  be  regarded  with  sus- 
picion. Data  of  the  kind  mentioned  are,  however,  often  difficult  to 
obtain,  and  it  should  be  borne  in  mind  that  not  every  case  of  mild 
rachitis  is  followed  by  pelvic  narrowing. 

Instruction  may  likewise  be  obtained  from  the  history  of  previous 
labors.  Though  a  protracted  and  difficult  labor  is  by  no  means 
uncommon  in  well-formed  primiparae,  it  should  stimulate  us,  both 
during  parturition  and  subsequent  to  delivery,  to  make  a  careful  inves- 
tigation as  to  the  capacity  of  the  pelvis.  A  pendulous  abdomen  and 
faulty  presentations  and  positions  of  the  foetus  occur  with  much  greater 
frequency  in  the  contracted  that  in  normal  pelves. 

Certain  of  the  rarer  deformities  proceed  from  inflammations  be- 
tween the  sacro-iliac  bones  and  at  the 
hip-joint,  from  inequalities  in  the 
length  of  the  limbs,  and  from  spinal 
distortion  when  these  difficulties  oc- 
cur in  early  childhood. 

Pelvic  Measureme7its. — The  ex- 
amination should  be  made  with  the 
patient  upon  her  back,  placed  prefer- 
ably upon  a  hard  table  covered  by 
a  folded  blanket,  or  a  woolen  com- 
forter. The  head  and  shoulders 
should  be  moderately  elevated,  the 
knees  should  be  flexed,  and  the  pel- 
vis brought  as  near  to  the  edge  of  the 
table  as  jDossible. 

Facility  in  the  recognition  of  ab- 
normal conditions  can  only  be  ac- 
quired by  making  it  a  habit  to  note 
the  general  features  of  the  pelvis  in  every  case  of  labor  which  is  com- 
mitted to  our  charge.  By  experience  we  acquire  a  tolerably  distinct 
idea  of  the  relative  thickness  of  the  bones,  the  inclination  of  the  ilia 
to  the  horizon,  the  height  and  angle  formed  by  the  symphysis  pubis, 
the  size  and  character  of  the  pubic  arch,  the  length,  breadth,  and 


196. — Baudelooque's  pelvimeter. 


CONTRACTED  PELVES. 


435 


curvature  of  the  sacrum,  the  position  of  the  promontory,  and  the  dis- 
tance between  the  ischia. 

More  exact  information  is  derivable  from  direct  measurements  be- 
tween different  prominent  points  in  the  pelvis.  Various  pelvimeters 
have  been  devised  to  facilitate  the  required  measurements.  Those  for 
determining  the  distance  between  certain  external  points  are  alone  of 
practical  value.  For  this  purpose  the  circle  of  Baudelocque  is  the  one 
I  have  most  constantly  employed.  It  requires  to  be  used  with  caution 
on  account  of  the  spring  of  the  metallic  arms.  Schultze's  instrument 
possesses  the  advantages  of  greater  firmness  and  portability.  The 
points  selected  for  measurement  should  be  bony  prominences,  easy  of 
recognition,  and  not  covered  by  soft  parts.    They  should  be  such  as 


to  allow  us  to  form  at  least  aj^proximative  conclusions  relative  to  the 
diameters  of  the  small  pelvis.  Experience  shows  us  that,  judged  by 
these  rules,  three  measurements  only  are  possessed  of  real  importance, 
viz.,  the  distances  between  the  anterior  superior  spinous  processes,  the 
distances  between  the  crests  of  the  ilia,  and  the  external  conjugate 
diameter. 

In  measuring  the  distances  between  the  anterior  suj^erior  spinous 
processes,  the  accoucheur  should  stand  by  the  side  of  his  patient,  and, 
holding  the  arms  of  the  pelvimeter  between  the  thumb  and  fingers, 
apply  the  points  of  the  instrument  to  the  spines  external  to  the  inser- 
tion of  the  sartorius  muscles.  The  points  should  then  be  pushed 
backward  a  number  of  times  along  the  outer  edge  of  the  crests  of  the 
ilia,  until,  after  a  few  trials,  the  greatest  distance  between  the  crests 
has  been  determined.  The  average  distances  thus  obtained  are  nearly 
ten  and  a  quarter  inches  between  the  spinous  processes,  and  eleven 
and  a  half  inches  between  the  crests  of  the  ilia.    A  pelvis  in  which 


Fig.  197. — Schultze's  pelvimeter. 


436 


THE  PATHOLOGY  OF  LABOR. 


these  measurements  are  equal,  or  in  which  the  relations  are  inverted 
(i.  e.,  where  the  distance  between  the  spinous  processes  is  greater 
than  that  between  the  crests  of  the  ilia),  is  rachitic  in  character.  In 
rachitic  pelves  of  the  second  variety  mentioned  it  is  customary  to 
select,  in  measuring  the  distance  between  the  crests,  points  situated 
two  and  a  half  inches  posterior  to  the  spinous  processes. 

Any  considerable  falling  below  the  normal  average  in  these  two 
diameters  would  warrant  the  diagnosis  of  transverse  shortening  in 
the  inner  dimensions  of  the  small  pelvis.  Deductions  as  to  the  degree 
of  shortening  should,  however,  be  made  with  caution,  as  the  relations 
between  the  diameters  of  the  large  and  small  pelves  depend  upon  such 
variable  factors  as  the  thickness  of  the  bones  and  integuments,  and 
the  height  and  inclination  to  the  horizon  of  the  ilia. 

In  measuring  the  external  conjugate  diameter  the  patient  is  turned 
upon  her  side  ;  one  extremity  of  the  pelvimeter  is  then  placed  upon 
the  fossa  just  beneath  the  spinous  process  of  the  last  lumbar  vertebra, 
while  the  anterior  point  is  made  to  rest  upon  the  middle  of  the  upper 
border  of  the  symphysis  pubis.  The  length  of  the  external  conjugate, 
or,  as  it  is  sometimes  termed  from  its  author,  the  diameter  of  Baude- 
locque,  is  normally  about  eight  inches.  Baudelocque  thought  that  by 
deducting  three  inches  from  the  external  conjugate  in  spare  women, 
and  three  and  a  quarter  inches  in  women  of  a  fleshy  habit,  the  conju- 
gata  vera  could  be  determined.  Litzmann  has,  however,  strikingly 
shown  the  fallacy  of  Baudelocque's  deduction.  In  thirty  cases,  where 
he  had  an  oi)portunity  to  compare  the  measurements  of  the  external 
conjugate  with  the  length  of  the  internal  conjugate  as  determined  sub- 
sequently by  post-mortem  examination,  he  found  the  mean  amount  to 
be  deducted  was  about  three  and  a  half  inches.  However,  the  amount 
in  individual  cases  widely  varied,  owing  to  differences  in  the  thickness 
of  the  bones  and  integuments,  the  maximum  amounting  to  nearly 
five  inches,  while  the  minimum  did  not  exceed  two  and  three  fourths 
inches.  But,  while  the  external  conjugate  does  not  enable  us  to 
estimate  to  a  fraction  the  length  of  the  antero-posterior  diameter  of 
the  pelvic  brim,  it  furnishes  useful  information  as  to  the  existence  in 
general  of  flattening.  Thus,  if  the  diameter  of  Baudelocque  measures 
less  than  six  and  one  fourth  inches,  it  may  be  assumed  that  the  pelvis 
is  flattened.  If  the  pelvis  measures  less  than  seven  and  a  half  inches, 
flattening  may  be  assumed  in  half  the  cases.  Above  seven  and  a  half 
inches,  antero-posterior  shortening  is  very  exceptional.* 

For  internal  measurements,  the  only  practical  pelvimeter  is  the 
hand  of  the  accoucheur.  To  be  sure,  it  can  only  determine  with  exac- 
titude the  diagonal  conjugate,  i.  e.,  the  distance  from  the  lower  border 
of  the  symphysis  pubis  to  tlie  promontory  ;  but  from  the  diagonal 

■*  LiTZMANX,  "  Uebcr  die  Erkenntniss  des  engen  Beckens,"  Volkmann's  "  Samml. 
klin.  Vortr.,"  No.  20,  p.  148. 


CONTRACTED  PELVES. 


437 


conjugate  it  is  possible  to  calculate  the  conjugata  vera  with  a  closer 
degree  of  accuracy  than  is  obtainable  by  means  of  any  of  the  ingenious 
instruments  designed  to  measure  directly  the  diameters  of  the  brim. 

To  ascertain  the  diagonal  conjugate,  the  index  and  middle  fingers 
of  the  left  hand  should  be  introduced,  well  oiled,  into  the  vagina.  By 
pushing  the  posterior  vaginal  wall  backward,  the  points  of  the  fingers 
are  made  to  reach  the  sacral  vertebrae.  Then,  following  the  sacrum 
upward,  the  promontory  is  reached.  To  do  this  it  is  necessary  to  sink 
the  elbow,  and  give  to  the  fingers  a  nearly  vertical  direction.  The 
resistance  of  a  rigid  perinaeum  and  the  vaginal  wall  is  best  overcome 
by  continued,  steady,  upward  pressure.  It  is  often  possible  by  this 
method  to  reach  the  promontory  in  even  normal  pelves.  During  the 
examination  the  patient  should  be  requested  to  raise  up  her  hips.  The 
promontory  is  recognized  partly  by  its  convex  surface,  and  partly  by 
the  width  of  the  cartilage  which  intervenes  between  it  and  the  ad- 
joining lumbar  vertebra.  In  practice  there  are  two  possible  sources  of 
error,  viz. :  an  angle  may  form  between  the  first  and  second  sacral 
vertebrae  where  the  union  has  been  incomplete,  producing  a  false 
promontory  "  beneath  the  true  one  ;  or  the  upper  surface  of  the  first 
lumbar  vertebra  may  project  in  such  a  way  as  to  be  mistaken  for  the 
promontory  in  cases  where  the  latter,  as  sometimes  happens,  forms 
with  the  spinal  column  a  very  obtuse  angle.*  Such  deviations  are 
not  without  practical  interest,  as  the  prognosis  is  rendered  less  promis- 


Fio.  198. — Normal  inclination  Fio.  199. — Diminution  of  angle  Fjg.  200. — Increase  of  angle 
of  the  symphysis  pubis.  between  symphysis  and  pel-  between  symphysis  and 
(Spiegelberg.)  vie  brim.  pelvic  brim. 


ing  when  the  head,  in  place  of  a  single  point  of  contact,  has  to  over- 
come the  resistance  offered  by  the  surface  of  an  entire  vertebra. 

The  measure  of  the  diagonal  conjugate  is  taken  by  pressing  the 

*  LiTZMANN,  "  Ueber  die  Erkenntniss  des  engen  Beckens,"  Volkmann's  "  Samml.  klin. 
Vortr.,"  No.  20,  pp.  152,  153. 


438 


THE  PATHOLOGY  OF  LABOR. 


middle  finger  firmly  against  the  most  salient  portion  of  the  promon- 
tory, while  the  radial  edge  of  the  hand  or  index-finger  is  raised  to  the 
ligamentum  arcuatum.  The  point  of  contact  with  the  latter  is  then 
carefully  marked  with  the  nail  of  the  index-finger  of  the  right  hand. 
It  is  desirable  in  withdrawing  the  fingers  that  they  maintain,  as  nearly 
as  may  be,  the  position  assumed  at  the  time  of  measurement.  Finally, 
with  a  small  rule,  the  length  from  the  mark  of  the  nail  to  the  tip  of 
the  finger  is  readily  ascertained. 

In  calculating  the  length  of  the  conjugata  vera  from  the  measure 
thus  gained,  it  is  necessary  to  reconstruct  the  triangle  formed  by  the 
two  conjugates  and  the  symphysis  pubis.  The  diagonal  conjugate  is 
the  largest  of  the  three  sides.  The  length  of  the  conjugata  vera  de- 
pends on  the  height  and  inclination  of  the  symphysis  pubis,  and  the 
degree  of  elevation  of  the  promontory  above  the  symphysis,  as  may  be 
readily  seen  by  reference  to  the  diagrams. 

The  height  of  the  symphysis  pubis  may  be  determined  by  the 
finger  through  the  anterior  vaginal  wall.  When  the  symphysis  does 
not  measure  above  one  inch  and  a  half,  the  subtraction  of  two  thirds 
of  an  inch  from  the  diagonal  diameter  will,  under  ordinary  circum- 
stances, furnish  very  nearly  the  conjugate.  When  the  symphysis  ex- 
ceeds one  inch  and  a  half,  three  fourths  of  an  inch  should  be  de- 
ducted.* 

The  inclination  of  the  symphysis  pubis  to  the  plane  of  the  brim 
and  the  height  of  the  promontory  above  the  upper  border  of  the  pubes 
can  only  be  estimated.  When  any  unusual  deviations  in  either  of 
these  regards  are  found  to  exist,  some  special  allowance  would  need 
to  be  made  by  way  of  compensation.  It  is  just  here  that  judgment 
ahd  experience  furnish  the  best  safeguards  against  vital  inaccura- 
cies. 

In  thin  persons,  during  the  non-pregnant  state,  the  promontory 
can  sometimes  be  easily  reached  through  the  abdominal  walls,  and  an 
estimate  made  of  the  conjugate  by  deducting,  from  the  distance  thus 
obtained  between  the  promontory  and  the  symphysis,  the  supposed 
thickness  of  the  intervening  tissues. 

The  transverse  diameters  of  the  pelvic  brim  and  cavity  can  be 
neither  directly  measured  nor  calculated  with  any  degree  of  certainty 
from  other  measurements. 

There  are  certain  other  dimensions  which  we  find  useful  to  deter- 
mine in  the  rarer  forms  of  distortion,  and  which  will  be  mentioned  in 
their  proper  connections.  For  the  three  forms  of  contracted  pelvis 
which  at  present  engage  our  attention,  four  measurements  alone  are  of 
practical  value — viz.,  the  distance  between  the  anterior  superior  spi- 
nous processes  ;  the  distance  between  the  crests  of  the  ilia  ;  the  external 
conjugate  ;  and  the  conjugata  diagonalis. 

*  Spiegelberg,  op.  cit.y  p.  433. 


CONTRACTED  PELVES. 


439 


The  Three  Principal  Forms  of  Contracted  Pelvis. 

Hie  Pelvis  ^quabiliter  Judo-Minor,  or  Symmetrically  Contracted 
Pelvis. — This,  the  rarest  of  the  three  forms,  presents  to  the  casual 
view  the  appearance  of  a  normal  pelvis,  except  that  the  diameters  from 
the  brim  to  the  outlet  are  reduced  in  nearly  equal  measure.  We  dis- 
tinguish two  varieties  of  this  pelvis  ;  1.  In  the  commoner  variety  the 
woman  may  be  of  small,  medium,  or  large  stature,  and  her  figure 
thick-set,  or,  on  the  contrary,  graceful  and  slender.  Nothing  in  either 
her  size  or  carriage  is  indicative  of  any  abnormal  condition.  The 
pelvic  bones  themselves,  both  in  their  structure  and  in  their  connec- 
tions with  one  another,  are  free  from  all  traces  of  morbid  action. 
They  are  simply  below  the  standard  size.  The  pelvis  as  a  whole  is  of 
the  feminine  type.  Litzmann  has  shown,  however,  that  in  the  justo- 
minor  pelvis  the  relations  of  the  different  parts  to  one  another  are  not, 
as  a  rule,  absolutely  the  same  as  in  the  normal  pelvis.  Thus,  there 
is  diminished  width  of  the  sacrum,  due  in  special  degree  to  the  small 
size  of  the  alse ;  the  rotation  forward  of  the  promontory  and  the  curv- 
ing of  the  lower  extremity  of  the  sacrum  are  less  pronounced  ;  the  con- 
cavity of  the  sacrum  in  the  transverse  direction  is  increased  ;  the  pos- 
terior sacral  surface  is  nearly  on  a  level  with  the  posterior  superior 
spinous  processes  in  place  of  sinking  forward  between  the  ilia ;  the 
height  of  the  anterior  and  lateral  walls  is  proportionately  lessened  ; 
and,  finally,  there  is  often  an  increase  in  the  angle  which  the  symphysis 
pubis  forms  with  the  conjugate.* 

These  peculiarities  point  to  a  premature  arrest  in  the  develop- 
ment of  the  bones,  whereby  the  pelvis  retains  something  of  the  infan- 
tile type.  The  causes  of  arrest  are  in  most  cases  traceable  to  general 
disturbances  of  nutrition  during  early  childhood,  such  as  scrofula  and 
chlorosis,  to  rickets,  which  in  place  of  leading  to  deformity  exception- 
ally exerts  its  influence  in  the  suspension  of  bone-growth,  and  in  rare 
cases  to  the  influence  of  hard  labor  and  the  carrying  heavy  weights 
before  the  completed  development  of  the  body.  A  few  cases  in  which 
no  morbid  conditions  can  be  elicited  from  the  history  of  the  patient 
may  perhaps  be  referred  to  some  original  defect  in  the  primitive  ma- 
terial from  which  the  bones  were  built  up.  Cases  have  been  reported 
in  which  this  anomaly  appeared  to  be  hereditary. f 

2.  In  veritable  dwarfs  the  diminutive  size  of  the  pelvis  may  simply 
correspond  to  the  Lilliputian  proportions  of  the  entire  skeleton.  These 
so-called  dwarf  pelves — pelves  nance — are  of  the  regular  feminine  type, 
but  the  bones  are  slight,  and  united,  as  in  the  child,  by  cartilage. 

*  LiTZMANK,  "  Die  Formen  dos  Beckens,"  Berlin,  p.  40. 

f  MicHAELis,  "Das  enge  Becken,"  herausgegeben  von  Litzmann,  p.  190;  vide  like- 
wise, LoHLEiN,  "  Zur  Lehre  vom  Durehweg  zu  engen  Becken,"  "  Ztschr.  f.  Geburtsh.  u. 
Frauenkr,,"  Bd.  i,  p.  53. 


440  THE  PATHOLOGY  OF  LABOR. 


They  are  extremely  rare.  In  pelves  of  this  variety  the  highest  degree 
of  contraction  is  observed.* 


Fig.  201. — Specimens  from  the  Wood  Museum  (Bellevue  Hospital).    Drawn  on  same  scale. 
No.  1.  Normal  pelvis.    No.  2.  Justo-minor  pelvis,  f 


Diagnosis. — In  the  justo-minor  pelvis  all  the  external  diameters  are 
diminished.  At  the  same  time,  rickets  is  excluded  by  the  normal 
relations  existing  between  the  spines  and  the  crests  of  the  ilia  (vide  p. 
436).  The  diagonal  conjugate  is  lessened.  In  estimating  the  conjugata 
vera  it  is  necessary  carefully  to  notice  the  height  of  the  promontory, 
and  the  inclination  of  the  anterior  pelvic  wall,  as  these  are  sometimes 

*  There  is  a  third  form  of  justo-minor  pelvis,  which  is  the  concomitant  of  undeveloped 
organs  of  generation.  As  it  occurs  only  in  sterile  women,  it  possesses  no  obstetrical  interest. 

f  Primipara,  aged  twenty-three.  In  labor  three  days  previous  to  my  seeing  her. 
Waters  all  escaped.  Large  scalp-tumor  reaching  nearly  to  vulva.  Cervix  rigid.  Os  one 
third  dilated  and  pushed  down  by  scalp-tumor.  Forceps  tried.  Afterward  perforation 
and  craniotomy.  Chin  tilted  and  head  brought  through  the  pelvis  by  the  f ronto-mental 
diameter.  Patient  died  on  third  day.  Extensive  marks  of  pressure  in  the  bladder  oppo- 
site pelvic  rami.  Small  circular  perforation  of  uterus  opposite  promontory.  Conjugate 
diameter  three  inches.  Transverse  diameter  of  brim  four  and  a  half  inches.  Slight  Nae- 
gele  obliquity  on  left  side.  Patient  was  fifty -nine  inches  in  height,  and  presented  no 
signs  of  rickets. 


CONTRACTED  PELVES. 


441 


exaggerated  and  call  for  an  increase  in  the  amount  to  be  deducted.* 
By  careful  palpation  of  the  two  sides  of  the  pelvis  with  the  half-hand 
introduced  into  the  vagina,  the  fact  but  not  the  degree  of  transverse 
shortening  may  be  recognized.  Still,  in  this  way  the  existence  of  ex- 
treme contraction  would  be  noticed.  In  ordinary  cases,  it  is  fortunately 
safe  to  base  practice  upon  the  length  of  the  antero-posterior  diameter. 

Flattened  Pelvis. — We  have  seen  that  the  characteristic  of  this 
form  is  a  shortened  conjugate  diameter.  The  transverse  diameter 
remains  at  the  same  time  normal,  or  may  sink  below  the  standard. 
A  special  distinction  is  likewise  to  be  made  between  the  flattened  pel- 
ves of  non-rachitic  and  rachitic  origin  : 

1.  The  flattened  non-rachitic  form  is  the  most  frequent  variety  of 
contracted  pelvis.  At  a  first  glance,  or  previous  to  measurement,  it 
often  produces  the  impression  of  a  normal,  well-formed  pelvis.  It  is 
occasioned  by  a  sinking  of  the  sacrum  downward  and  inward  between 
the  two  ilia.  As  this  movement  takes  place  without  any  forward  rota- 
tion of  the  promontory,  the  antero-posterior  shortening  is  not  confined 
to  the  brim,  but  extends  throughout  the  entire  pelvic  cavity.  Extreme 
contraction  is  uncommon,  the  length  of  the  conjugate  rarely  falling 
below  three  inches.  The  flattening  is  of  necessity  associated  with  a 
compensating  increase  in  the  transverse  diameter.  As,  however,  the 
flattened  non-rachitic  pelvis  is  usually  from  the  outset  of  small  size, 
the  compensation  hardly  suffices  to  give  to  the  transverse  diameter 
more  than  the  normal  dimensions.  Indeed,  it  is  not  infrequent  to 
find  a  slight  lessening  in  the  transverse  diameter  associated  with  an- 
tero-posterior contraction. 

There  is  nothing  definitely  settled  regarding  the  etiology  of  this 
deformity.  It  has  been  attributed  to  lifting  and  carrying  heavy  bur- 
dens before  the  age  of  puberty,  to  incompletely  developed  rickets,  and 
to  retarded  development. 

During  life  it  is  not  easy  to  distinguish  between  this  form  and  that 
of  the  symmetrically  contracted  pelvis.  In  both  the  external  signs  of 
rickets  are  absent,  the  relations  between  the  spines  and  crests  of  the 
ilia  normal,  and  in  both  all  the  external  diameters  may  be  somewhat 
dimmished.  The  stature  of  the  individual  furnishes  no  clew ;  for, 
though  both  forms  occur  rather  more  frequently  in  diminutive  persons, 
there  are  numerous  exceptions  to  the  rule.  The  sinking  of  the  sacrum 
between  the  ilia  is  not  easy  to  recognize.  In  a  well-marked  example, 
however,  the  relatively  greater  shortening  of  the  conjugata  externa 
and  the  diagonal  conjugate,  f  with  the  difficulty  of  palpating  the  inner 

*  On  the  contrary,  owing  to  the  shortness  of  the  symphysis  pubis,  as  a  rule,  the  aver- 
age amount  to  be  deducted  is  rather  less  than  in  normal  pelves.  Lohlein  ("Kunsthvilfe 
bei  der  allg.  Beckenenge  ")  found  the  average  in  eighteen  cases  was  three  fifths  of  an  inch. 

f  In  reckoning  the  true  conjugate  from  the  diagonal  diameter,  the  same  reduction 
needs  to  be  made  as  in  the  normal  pelvis,  for,  though  the  outward  slant  of  the  symphysis 


442 


THE  PATHOLOGY  OF  LABOR. 


surface  of  the  pelvic  lateral  walls,  furnish  the  prominent  points  for 
guidance.  Sometimes,  when  no  bony  union  has  formed  between  the 
first  and  second  sacral  vertebrag,  a  double  promontory  may  be  felt. 

2.  The  rachitic  form  of  flattened  pelvis  presents  the  following 
characteristics  : 

The  bones  are  of  small  size,  but  usually  of  normal  texture.  Some- 
times, however,  they  are  thin,  and  even  translucent,  while  in  other 
instances  they  may  be  unusually  compact  and  thickened.   The  ilia  are 

flattened,  and  run  in  a  near- 
ly horizontal  direction.  The 
anterior  superior  spinous 
processes  flare  outward,  so 
that  the  distance  between 
them  differs  little  from  that 
between  the  widest  points 
of  the  crests.  The  promon- 
tory projects  inward  toward 
the  symphysis  pubis.  The 
upper  portion  of  the  sacrum 
sinks  inward  between  the 

Fig.  202.— Flattened  rachitic  pelvis.     (Wood's  Mu-  ilia,  and  lies  farther  in  front 

of  the  posterior  superior 
spinous  processes  than  in  the  normal  pelvis.  The  upper  portion,  too, 
is  directed  nearly  horizontally  backward,  while  the  extremity,  usually 
at  the  fourth  or  fifth  sacral  vertebra,  is  bent  sharply  forward.  The 
anterior  sacral  surface  loses  its  transverse  concavity,  and  becomes  either 
flat  from  side  to  side,  or  convex  from  the  bulging  forward  of  the  sa- 
cral vertebrae.  The  antero-posterior  shortening  of  the  brim  is  accom- 
panied by  a  compensating  increase  in  the  transverse  diameter.  As, 
however,  the  rachitic  pelvis  is  originally  undersized,  the  transverse 
diameter  rarely  exceeds  normal  dimensions.  The  horizontal  rami  of 
the  pubes  are  flattened,  and  the  acetabula  are  directed  to  the  front. 
The  cartilage  of  the  symphysis  pubis  generally  projects  inward,  the 
pectineal  line  is  often  unusually  sharp,  and  at  times  terminates  at  the 
insertion  of  the  psoas  muscle  in  a  projecting  spine.  Below,  the  ischia 
diverge  from  one  another,  and  the  arch  of  the  pubes  is  Avidened. 

The  result  of  these  changes  is  to  produce  a  shallow  pelvis,  with 
contraction  at  the  brim,  and  widening  at  the  outlet.  The  shape  of 
the  brim  varies  between  a  long  ellipse  and  that  of  a  heart  or  kidney, 
the  different  degrees  of  variation  depending  upon  the  extent  of  the 
displacement  forward  of  the  promontory.  Externally,  owing  to  the 
horizontal  position  of  the  sacrum,  a  depression  exists  in  the  lumbar  re- 
is  increased,  this  is  compensated  for  by  the  diminished  lieight  of  the  symphysis  and  low 
position  of  the  promontory.  (Litzmann,  Volkmann's  "  Samml.  klin.  Vortr.,"  No.  20, 
p.  160. 


CONTRACTED  PELVES.  443 

non,  the  sulcus  between  the  nates  is  broad  and  superficial,  and  the  anal 
[orifice  is  exposed  to  view. 

To  appreciate  the  rachitic  pelvis,  it  is  necessary  to  bear  in  mind  the 
[changes  wrought  by  rickets  in  the  bony  structures.  In  the  physiolog- 
lical  growth  of  the  pelvic  bones,  new  cell-elements  develop  beneath  the 
tperiosteum  and  adjacent  to  the  cartilaginous  borders  upon  the  articular 
[gurfaces.  These  cell-elements  promptly  ossify,  and  thus  provision  is 
[made  for  the  increase  of  the  bones  in  extent  and  thickness.  Simulta- 
neously with  the  formation  of  the  new  bone,  medullary  spaces  are  pro- 
Iduced  in  the  bony  tissues  by  a  process  of  absorption.  Now,  in  rickets, 
while  the  new  cell-elements  are  deposited  in  such  numbers  that  the 
preparatory  layer  is  often  five  to  ten  times  the  normal  thickness,  the 
process  of  ossification  is  suspended  or  imperfectly  performed.  Thus, 
the  rachitic  pelvis  consists  of  a  number  of  more  or  less  firm,  bony 
masses,  covered  with  soft  osteoid  layers,  with  broad  cartilaginous  bor- 
ders at  the  articular  surfaces.  These  changes  combine  to  increase  the 
pliability  of  the  pelvis,  and  to  retard  its  growth. 

The  pelvic  deformity  resulting  from  rickets  is  mainly  due  to  the 
weight  of  the  superimposed  body.  The  pressure  from  above  which  the 
trunk  exerts  pushes  the  promontory  forward  toward  the  median  line. 
At  the  same  time  the  upper  portion  of  the  sacrum  rotates  upon  its 
transverse  axis,  so  that  its  posterior  aspect  is  nearly  on  a  line  with  the 
horizon.  The  bodies  of  the  vertebrae  sink  downward  between  the  flex- 
ile wings,  whereby  the  concavity  of  the  sacrum  from  side  to  side  is 
effaced.  The  pliant  border  of  the  iliac  articulation  yields  somewhat, 
and,  as  it  is  drawn  inward  by  the  sinking  of  the  sacrum,  the  traction 
of  the  strong  sacro-iliac  ligaments  approximates  the  posterior  superior 
spinous  processes  to  one  another.  The  traction  of  the  sacro-tuberous 
and  sacro-spinous  ligaments  aids  in  hooking  forward  the  lower  extrem- 
ity of  the  sacrum,  though  to  this  deformity  the  pressure  exercised 
upon  the  end  of  the  spinal  column  by  the  half -sitting,  half -recumbent 
posture,  affected  by  rachitic  children,  unquestionabl}^  contributes  its 
part. 

If  we  regard  the  sacrum  as  a  fulcrum,  and  each  os  innominatum  as 
a  lever,  it  is  evident  that  the  traction  of  the  sacro-iliac  ligaments,  under 
the  pressure  upon  the  sacrum  from  the  trunk,  would  produce  a  separa- 
tion of  the  innominate  bones  in  front  were  it  not  for  their  firm  union 
at  the  symphysis  pubis.  The  result  of  these  two  counteracting  forces 
is  an  increased  incurvation  of  the  bones  at  the  point  of  weakest  resist- 
ance, which  is  situated  near  the  auricular  surfaces.  In  advanced  rick- 
ets, where  the  bones  are  plastic  and  willowy,  the  linea  arcuata  is  often 
bent  at  an  angle,  so  that  the  greatest  transverse  diameter  divides  the 
pelvic  brim  into  a  posterior  and  anterior  half.  To  the  latter  belong 
the  acetabula,  to  the  former  the  two  ilia. 

The  outward  direction  of  the  anterior  superior  spinous  processes  is 


444 


THE  PATHOLOGY  OF  LABOR. 


probably  due  in  a  measure  to  an  arrest  of  develojoment,  as  the  S-shaped 
curve  of  the  crests  of  the  ilia  does  not  normally  develop  until  after  the 
age  at  which  rickets  usually  makes  its  appearance  (Kehrer).  The  flat- 
tening of  the  ilia  is  partly  due  to  the  drag  of  the  sacro-iliac  ligaments, 
and  partly  to  the  action  of  the  sartorii  and  gluteal  muscles.  The  di- 
vergence of  the  ischia  and  the  wide  arch  of  the  pubes  are  the  product 
of  the  increased  transverse  diameter,  and  the  attachments  of  the  ro- 
tator and  adductor  muscles  of  the  thigh.* 

The  diagnosis  of  the  rachitic  form  of  flattened  pelvis  is  easy,  if  the 
characteristic  changes  are  kept  in  mind.  The  prominent  features  to 
which  the  attention  needs  to  be  directed  are  :  the  relations  of  the  dis- 
tances between  the  cristas  ilii  and  the  anterior  superior  spinous  proc- 
esses (diminished  difference,  or  distance,  between  the  anterior  superior 
spinous  processes  may  equal,  or  even  exceed,  that  between  the  crests) ; 
diminished  distance  between  the  posterior  superior  spinous  processes  ; 
diminution  of  the  external  conjugate  ;  the  form  and  direction  of  the 
sacrum  ;  the  shape  of  the  arcus  pubis,  and  the  marked  projection  of 
the  promontory.  A  false  promontory  at  the  second  sacral  vertebra  is 
not  uncommon.  The  deduction  to  be  made  from  the  conjugata  diago- 
nals in  estimating  the  conjugata  vera  averages  the  same  as  in  the 
normal  pelvis.  However,  it  is  in  rachitic  pelves  that  the  widest  varia- 
tions in  this  respect  occur,  making  it  specially  necessary  in  each  case 
to  observe  the  height  of  the  promontory  and  the  length  and  direction 
of  the  symphysis  pubis. 

Flattened  Generally  Contracted  Pelves. — In  this  variety  we  distin- 
guish likewise  a  rachitic  and  non-rachitic  form,  the  latter  occurring 
rarely,  the  former  with  comparative  frequency. 

The  non-rachitic  form  is  apparently  the  joint  product  of  a  small 
justo-minor  pelvis  and  the  forces  which  lead  to  a  sinking  of  the  sa- 
crum between  the  ilia.  In  these  pelves  a  short  symphysis  and  a  low 
promontory  contribute  often  to  reduce  greatly  the  difference  between 
the  diagonal  and  the  true  conjugate.  During  life  it  is  difficult  to  dis- 
tinguish it  from  the  justo-minor  pelvis. 

The  rachitic  form  is  found  usually  in  persons  of  small  stature.  It 
presents  in  a  striking  degree  the  marked  peculiarities  of  the  rachitic 
pelvis.    The  existence  of  transverse  narrowing  is  recognized  by  the 

*  While  Litzmann  ("  Die  Formen  des  Beckens  ")  and  Schroeder  ("  Lehrbuch  der  Ge- 
burtshiilfc  ")  lay  special  stress  upon  the  weight  of  the  body  as  the  main  factor  in  produc- 
ing the  deformities  of  rickets,  Kehrer  ("  Zur  Entvvickelungs  Geschichte  der  rachit. 
Beckens,"  "Arch.  f.  Gynaek.,"  Bd.  v,  18*72,  p.  55)  has  shown  that  many  of  the  changes 
characteristic  of  rickets  occur  in  congenital  cases — i.  c.,  before  the  action  of  the  weight 
of  the  trunk  is  brought  into  play.  Kehrer  refers  the  changes,  therefore,  in  the  main, 
to  muscular  action.  Fchling  ("Die  Entstehung  der  rachit.  Beckens,"  "Arch.  f.  Gynaek.," 
Bd.  xi,  p.  173)  ascribes  the  deformities  in  rickets  to  disturbances  of  growth  and  per- 
sistence of  the  fetal  type.  Engel  ("Wiener  med.  Wochenschrift,"  1872,  No.  40)  sought 
to  prove  the  deformities  to  be  the  result  of  partially  arrested  growth. 


CONTRACTED  PELVES. 


445 


narrowness  of  the  hips,  by  the  ease  with  which,  in  internal  examina- 
tion, tlie  side -walls  can  be  felt  with  the  palmar  surface  of  the  half- 
hand,  and  by  the  modifications  it  produces  in  the  mechanism  of  labor. 

Irregular  Rachitic  Pelves. — For 
convenience'  sake  it  seems  desirable 
to  attach  to  the  description  of  the 
flattened  form  the  influence  of  two 
additional  forces,  which,  upon  occa- 
sion, operate  to  still  further  modify 
the  shape  of  the  rachitic  pelvis. 
These  are  lateral  pressure  of  the  heads 
of  the  thigh-bones  at  the  acetabula 
and  the  various  forms  of  spinal  curva- 
ture which  so  'commonly  result  from 

inlrof-'  Fig.  203. — Small  symmetrical  rachitic 

riCKeite.  pelvis.    (Wood's  Museum.) 

Pressure  at  the  acetabula  is  rarely 
an  operative  force,  because  rickets  usually  is  developed  at  the  time  of 
the  first  dentition — i.  e.,  before  the  child  has  learned  to  walk — and  it 
is  not  until  after  the  disease  has  declined  that  the  child  attempts  to 
use  its  lower  extremities.  In  the  exceptional  cases  in  which  the  dis- 
ease occurs  later,  after  the 
child  has  begun  to  walk,  the 
lateral  pressure  may  act  in 
either  one  of  two  ways  : 

1.  As  a  counteracting  force 
to  that  exercised  by  the  weight 
of  the  trunk,  in  which  case 
the  pelvis,  provided  the  path- 
ological processes  have  only 
Fig.  204.— Pseudo-osteomaiacia.  (Naegelc.)      advanced  to  a  limited  extent, 

retains  a  symmetrical  appear- 
ance, and  resembles  closely  the  justo-minor  pelvis.  The  rachitic  ori- 
gin is  betrayed  by  the  shape  of  the  ilia  and  the  signs  of  rickets 
in  other  parts  of  the  body.  At  the  outlet  the  antero-2:>osterior  di- 
ameter is  increased,  and  the  transverse  diameter  somewhat  dimin- 
ished.* 

2.  In  cases  of  excessive  softening  of  the  bones,  either  from  the  se- 
verity or  the  long  duration  of  the  disease,  the  acetabula  are  sometimes 
pushed  inward,  upward,  and  backward,  and  the  symphysis  pushed 
forward,  so  that  the  rami  of  the  pubes  meet  at  an  acute  angle,  or  run 
nearly  parallel  to  one  another.  This  lateral  compression,  in  conjunc- 
tion with  the  rachitic  projection  of  the  promontory,  gives  to  the  pelvic 
brim  a  triangular  or  clover-leaf  shape,  closely  resembling  the  distor- 
tion produced  in  osteomalacia.  The  term  pseudo-osteomaiacia  given 
*  ScHROEDKR,  "  Schwangorschaft,  Geburt.  und  Wochenbett,"  p.  77. 


446 


THE  PATHOLOGY  OF  LABOR. 


by  Michaelis  *  to  this  form  is  warranted  by  the  existence  of  certain 
features  peculiar  to  rickets,  such  as  the  small  size  of  the  ilia,  the  dis- 
tance between  the  anterior  superior  spinous  processes,  and  the  nature 
of  the  changes  in  other  parts  of  the  bony  skeleton. f 

In  curvatures  of  the  spine  the  shape  of  the  pelvis  is  affected,  when 
a  compensatory  scoliosis  or  kyphosis  includes  the  sacral  extremity  : 

1.  In  scoliosis  (lateral  curvature),  all  the  rachitic  features  are  usu- 
ally strongly  pronounced.  The  promontory  is  tilted  to  the  side  of  the 
incurvation,  and  is  pressed  by  the  weight  of  the  body  toward  the  cor- 
responding acetabulum.  The 
ilium,  owing  to  the  increased 
pressure  at  the  acetabulum  from 
the  femur  of  the  affected  side, 
is  pushed  upward,  backward, 
and  inward.  In  extreme  cases 
the  approximation  of  the  prom- 
ontory to  the  acetabulum  may 
be  such  as  to  prevent  the  en- 
trance of  the  child's  head.  The 
contracted  portion  becomes, 
therefore,  unavailable  for  ob- 
stetrical purposes  I"        p.  488). 

2.  In  kyphosis  (posterior 
curvature)  many  of  the  charac- 
teristic features  of  the  rachitic 
pelvis  are  reversed.  As  the 
upper  portion  of  the  sacrum  is 
tilted  backward,  either  the  con- 
jugata  vera  is  increased,  or  the 
previous  rachitic  antero-poste- 
In  the  movement  of  the  sacrum 
upon  its  transverse  axis  the  lower  extremity  is  thrown  forward,  and 
the  conjugate  of  the  outlet  is  thereby  reduced.  Kyphosis,  occurring 
at  the  beginning  of  rickets,  diminishes  the  distance  between  the  tu- 
berosities of  the  ischia,  but  has  little  effect  upon  the  inferior  transverse 
diameter  after  the  rachitic  changes  have  once  been  accomplished. 

Influence  of  the  Contkacted  Pelvis  upon  Pregnancy  and 

Labor. 

The  influence  of  the  contracted  pelvis  is  not  confined  simply  to  the 
embarrassment  which  the  form  and  size  of  the  pelvis  afford  to  the 

*  Michaelis,  "Das  cngc  Becken,"  p.  139. 

f  The  supervention  of  true  osteomalacia  upon  rickets  has  been  observed.    ( Vide 
Spieoelderg,  "  Lchrbuch  dcr  Geburtshiilfc,"  p.  490.) 
jj.  LiTZMANN,  "  Die  Forinen  dcs  Beckens,"  p.  70. 


Fig.  205. — Scoliosis.  (Litzmann.) 

rior  narrowing  is  greatly  diminished. 


CONTRACTED  PELVES. 


447 


joassage  of  the  child  in  parturition  ;  it  extends  to  the  production  of  a 
multitude  of  remoter  effects,  which  are  often  regarded  by  the  unin- 
formed as  isolated  phenomena.  These  effects,  which  include  faulty 
positions  and  presentations  of  the  foetus,  unfavorable  shape  or  position 
of  the  uterus,  abnormal  character  of  the  pains,  and  the  like,  enter  in 
turn,  except  where  the  mechanical  difficulties  are  absolutely  insur- 
mountable, as  important  elements  in  the  determination  of  the  prog- 
nosis. For  our  knowledge  of  this  subject  we  are  indebted  almost 
wholly  to  the  enlightened  labors  of  the  Kiel  professors,  Michaelis* 
and  Litzmann.f 

Influence  of  the  Contracted  Pelvis  upon  the  Uterus  during  Preg- 
nancy.— In  the  early  months  the  only  way  in  which  the  contracted 
pelvis  exerts  an  influence  is  in  sometimes  favoring  the  dislocation  of 
the  uterus  backward.  This  action  is  liable  to  take  place  when,  in  the 
second  or  third  month,  the  uterus  has  been  unusually  depressed  in 
the  pelvis,  and  the  fundus  has  swung  backward  toward  the  sacrum 
as  the  uterine  axis  approximates  to  that  of  the  pelvic  outlet.  Under 
such  circumstances  the  jutting  of  the  rachitic  promontory  is  calcu- 
lated to  mechanically  interfere  later  with  the  ascent  of  the  organ  into 
the  abdominal  cavity,  in  which  case  the  pressure  of  the  inflated  intes- 
tines upon  the  anterior  aspect  of  the  uterus  pushes  the  fundus  over 
the  inclined  surface  of  the  sacrum,  and  retroversion  is  produced.  As 
the  gravid  uterus  enlarges,  owing  to  the  limited  space  within  the  pel- 
vis the  version  gradual  passes  into  a  flexion,  which,  unless  relieved, 
is  followed  by  symptoms  of  incarceration. 

In  the  latter  months  of  gestation,  the  uterus,  as  a  rule,  is  lifted  to 
a  greater  extent  above  the  pelvis  than  occurs  under  normal  conditions. 
This  elevation  is  due  to  the  growth  of  the  child,  which  is  prevented 
from  sinking  into  the  pelvis  by  the  contracted  conjugate.  Sometimes 
the  upward  tendency  of  the  uterus  is  overcome  apparently  by  the 
resistance  of  the  round  ligaments,  so  that,  while  the  head  is  retained 
at  the  brim,  the  lower  segment  hangs  empty  in  the  pelvis.  At  the 
same  time  the  uterus  possesses  an  unusual  degree  of  mobility,  in  part 
due  to  the  lack  of  fixation  afforded  by  the  descent  of  the  foetus  into 
the  pelvis,  and  in  part  to  the  laxity  of  the  abdominal  walls  and  the 
round  ligaments.  These  latter  conditions  belong,  of  course,  rather  to 
multipara?  than  to  women  for  the  first  time  pregnant. 

In  close  connection  with  these  two  events,  viz.,  the  elevation  of 
the  uterus  and  its  mobility,  it  is  not  uncommon  to  observe  the  higher 
degrees  of  the  so-called  pendulous  abdomen,  caused  by  the  anteflexion 
of  the  gravid  uterus.  To  this  deformity,  furthermore,  the  small  stat- 
ure of  rachitic  patients,  the  increased  inclination  of  the  pelvis,  the 
anterior  projection  of  the  lumbar  portion  of  the  spine,  and  the  stretched 

*  MiCHAELis,  "  Das  enge  Becken,"  Leipsic. 

f  LiTZMANN,  Volkmann's  "Samml.  klin.  Vortr,,"  No.  23. 


448 


THE  PATHOLOGY  OF  LABOR. 


state  of  the  abdominal  walls,  associated  often  with  separation  of  the 
recti  muscles  at  the  linea  alba,  all  contribute  their  part. 

Influence  of  the  Contracted  Pelvis  npon  the  Presentation  of  the 
Foetus. — Faulty  presentations  occur  in  contracted  pelves  more  than 
three  times  as  frequently  as  in  those  of  normal  dimensions.*  Thus, 
when,  during  the  latter  part  of  pregnancy,  the  narrow  conjugate  me- 
chanically prevents  the  head  from  sinking  into  the  pelvic  cavity,  the 
head  frequently  glides  sidewise  or  forward,  to  rest  upon  an  iliac  fossa, 
or  upon  the  upper  border  of  the  symphysis  pubis.  In  pendulous  abdo- 
men the  uterus,  in  place  of  being  inclined,  when  the  patient  is  in  an 
upright  position,  at  an  angle  of  thirty-five  degrees,  becomes  nearly 
horizontal,  or  may  fall  forward  so  that  the  fundus  occupies  a  deeper 
position  than  the  inferior  segment  of  the  uterus.  The  great  mobility 
of  the  uterus  admits  likewise  of  extensive  lateral  movements.  These 
combined  causes  account  for  the  lack  of  stability  in  the  foetus  and 
the  comparative  frequency  with  which  shoulder  and  breech  presenta- 
tions occur.  When  the  head  is  fixed  at  the  brim,  the  conversion  of 
the  vertex  into  a  brow  or  face  presentation  is  often  simply  an  exag- 
geration of  the  normal  mechanism  of  labor  in  a  flattened  pelvis.  If 
the  head,  in  place  of  filling  the  lower  segment  of  the  uterus,  is  re- 
tained at  the  brim,  the  space  left  between  the  head  and  the  uterine 
walls  favors  prolapse  of  the  cord  and  extremities.  In  like  manner,  in 
breech  presentations,  when  the  breech  is  detained  by  the  narrow  con- 
jugate, the  feet  are  apt  to  descend  first  into  the  vagina. 

Owing  to  the  progressive  relaxation  of  the  abdominal  and  uterine 
walls  with  successive  pregnancies,  the  frequency  of  these  irregularities 
increases  nearly  in  proportion  to  the  number  of  previous  births. 

Influence  of  the  Contracted  Pelvis  upon  the  Labor-Pains. — When 
the  degree  of  pelvic  contraction  permits  the  delivery  of  the  foetus  by 
the  normal  passages  without  resort  to  embryotomy,  the  favorable  or 
unfavorable  ending  of  the  labor  is  in  large  measure  dependent  upon 
the  character  of  the  pains.  Good  pains  are  of  vastly  more  consequence 
in  narrow  than  in  wide  pelves. 

Violent  pains,  where  the  mechanical  obstacles  are  insurmountable, 
either  from  the  smallness  of  the  pelvis,  the  faulty  presentation  of  the 
foetus,  the  position  of  the  child's  head,  or  its  size  and  hardness,  endan- 
ger the  integrity  of  the  uterus.  Indeed,  unless  the  mechanical  diffi- 
culties are  diminished  by  rectification  of  faulty  positions  and  presen- 
tations, or  by  embryotomy,  or  unless  relief  is  afforded  by  the  removal 
of  the  cliild  by  Cassarean  section,  there  is  reason  to  dread  in  such  cases 
the  occurrence  of  ruptured  uterus,  or,  after  retraction  of  the  cervix, 
that  the  uterus  may  be  torn  from  the  vagina. 

*  Spiegclbcrg  found  that,  of  544  labors  in  narrow  pelves,  the  head  presentation  oc- 
curred in  eighty-three  per  cent.,  whereas  the  proportion  is  ninety-five  per  cent,  in  normal 
pelves.    ("  Lehrbuch  der  Geburtshiilfc,"  p.  448.) 


CONTRACTED  PELVES. 


449 


Still  more  frequently  weak  pains  are  the  cause  of  unfavorable  ter- 
minations. Weak  pains  lead  to  lingering  labors.  Even  in  moderate 
degrees  of  contraction  they  fail  to  rectify  unfavorable  positions  of  the 
head,  or  to  force  the  head  by  the  brim  into  the  pelvis.  Under  such 
circumstances  neither  the  forceps  nor  version  can  be  employed  without 
serious  risk,  while,  if  a  waiting  policy  is  pursued,  the  amniotic  fluid 
gradually  escapes,  and,  as  the  uterus  retracts  down  closely  upon  its 
contents,  the  foetus  perishes  from  the  gradually  increasing  hindrances 
to  the  uterine  and  placental  circulation. 

In  prolonged  labors  good  pains  alternate  at  intervals  with  those  of 
less  force.  There  is  no  standard  by  which  the  quality  of  pains  j^er  se 
can  be  determined.  The  quality  of  the  pains  is  to  be  estimated 
rather  by  the  results  which  they  accomplish.  It  may  be  stated  as  a 
general  rule,  to  which,  however,  there  are  numerous  exceptions,  that 
the  strength  of  the  pains  is  proportioned  to  the  strength  of  the  resist- 
ance to  be  overcome.  Strong  pains  are  on  the  whole  rather  more  com- 
mon in  flattened  pelves,  and  weak  ones  in  pelves  contracted  in  all  their 
diameters,  without,  however,  the  rule  possessing  any  such  constancy 
as  to  lead  one  to  regard  the  form  of  the  pelvis  as  alone  possessing  any 
decisive  importance  in  the  production  of  the  result.* 

In  the  first  instance,  the  character  of  labor-pains  depends  upon 
the  innervation  of  the  uterus  and  upon  the  thickness  and  integrity  of 
its  muscular  structures.  The  resistance  which  the  narrow  pelvis  offers 
to  the  expulsion  of  the  child  increases  neces^rily  during  the  pains  the 
tension  and  irritation  of  the  uterine  walls  ;  and  these,  corresponding 
to  the  degree  of  irritability  and  contractility  of  the  organ,  may  pro- 
voke pains  of  unusual  violence,  which,  in  turn,  terminate,  when  the 
resistance  is  not  seasonably  overcome,  in  exhaustion ;  or  the  uterine 
activity  may  cease  without  any  previous  stage  of  increment ;  or, 
finally,  the  tension  and  injurious  pressure  of  the  uterus  may  lead  to 
local  circulatory  disturbances,  and  to  textural  changes  which  in  them- 
selves weaken  the  strength  of  the  contractions. 

Michaelis  observed  that  the  dangers  to  the  mother  and  child  grow, 
as  a  general  rule — to  which,  however,  there  are  numerous  exceptions — 
in  proportion  to  the  number  of  confinements.  The  increased  mortal- 
ity, especially  of  the  children,  he  attributed  to  a  peculiar  relaxation  of 
the  uterus  and  its  pelvic  attachments,  due  to  over-exertion  in  previous 
confinements.!  But  it  must  be  borne  in  mind  that  there  are  other 
results  of  contracted  pelves  which  directly  contribute  to  the  fatality  of 

*  Michaelis  thought  that  the  partial  pressure  of  the  promontory  and  symphysis  ex- 
cited increased  reflex  action  of  the  uterus  in  flattened  pelves,  whereas  the  complete  press- 
ure of  the  head  upon  the  brim  in  generally  contracted  pelves  exercised  a  paralyzing 
influence  (he.  cit.,  p.  185).  This  theory  has  been  called  in  question  by  both  Spicgelberg 
{loc.  cit,  p.  4.52)  and  Litzmann.    (Volkmann's  "  Samml.  klin.  Vortr.,"  No.  23,  p.  177.) 

f  Michaelis,  loc.  cit.,  p.  152. 
29 


450 


THE  PATHOLOGY  OF  LABOR. 


multiparous  labors.  Thus,  we  have  seen  that  pendulous  abdomen  and 
mobility  of  the  uterus  favor  abnormal  positions  and  presentations  of 
the  foetus,  complications  of  the  utmost  prognostic  importance  ;  and 
again,  that  the  displacements  of  the  gravid  uterus  occur  with  special 
frequency  when  the  abdominal  parietes  have  lost  their  supporting 
power  from  the  over-distention  of  previous  pregnancies.  Moreover, 
when  the  uterus  is  not  fixed  during  labor,  the  expulsive  action  of  the 
abdominal  walls  can  not  be  called  into  play,  and  thus  one  of  the  most 
important  auxiliary  forces  is  lost.  Further  sources  of  danger  lie  in 
the  increased  size  and  hardness  of  tlie  fetal  head  observed  in  later 
pregnancies,  and  in  the  residue  of  inflammatory  troubles  which  so 
often  proceed  from  the  first  difficult  delivery.  * 

Influence  of  the  Contracted  Pelvis  upon  the  First  Stage  of  Labor. — 
At  the  beginning  of  labor  the  head  in  contracted  pelves  is  usually  re- 
tained above  the  os  internum,  while  the  lower  segment  of  the  uterus 
hangs  empty  in  the  pelvic  cavity.  As,  under  these  circumstances, 
space  is  left  between  the  head  and  the  uterine  walls,  the  entire  column 
of  amniotic  fluid  acts  directly  during  the  pains  upon  the  cervix  uteri. 
The  dilatation  of  the  cervix  takes  place  gradually,  from  above  down- 
ward, as  expansion  follows  upon  the  descent  of  the  amniotic  sac.  The 
shape  of  the  bag  of  waters  depends  upon  the  greater  or  less  degree  of 
resistance  offered  by  the  cervical  walls.  If  the  latter  are  soft  and  dis- 
tensible, the  usual  semi-globular  contour  is  maintained.  If  the  cervix 
offers  any  material  resistance,  the  membranes,  if  sufficiently  elastic, 
protrude  through  the  external  os  in  cylindrical  form.  If,  finally,  the 
chief  opposing  force  to  dilatation  is  situated  at  the  os  internum,  a  con- 
striction may  take  place  at  that  point,  while  below  the  membranes 
assume  a  spheroid  shape.  As  the  result  of  these  conditions  an  unim- 
peded, wave-like  movement  of  the  amniotic  fluid  breaks  against  the 
protruding  membranes  during  the  pains,  the  shock  of  which  is  apt  to 
produce  premature  rupture,  an  event  which  is  all  the  more  inopportune, 
because  in  early  rupture  the  circumstances  all  favor  the  complete  dis- 
charge of  the  amniotic  fluid. 

After  the  rupture  of  the  membranes,  as  the  head  does  not  descend 
at  once  into  the  cervical  portion,  the  os  and  cervix  reclose,  though 
they  continue  dilatable  in  proportion  to  the  degree  of  distention  pre- 
viously accomplished.  Then,  as  under  the  influence  of  the  pains  the 
head  passes  into  the  pelvis,  it  gradually  once  more  unfolds  the  cer- 
vical canal,  and  completes  its  dilatation,  Should,  however,  the  head 
meet  with  any  considerable  resistance,  so  that  the  pressure  of  the  pel- 
vic brim  gives  rise  to  the  formation  of  a  scalp-tumor,  the  latter  serves 
to  dilate  the  cervical  canal  and  the  os  externum.  If  the  obstacle  is 
such  as  to  prevent  the  complete  descent  of  the  head,  two  results  are 
possible  : 

*  Spiegelberg,  "  Lchrbuch  dcr  Geburtshiilfc,"  p.  453. 


CONTRACTED  PELVES. 


451 


1.  If  the  pains  continue  strong,  and  no  measures  are  adopted  to 
remove  the  disproportion,  the  uterus  is  either  retracted  up  over 
the  head  of  the  child  as  it  remains  above  the  brim,  until  the  over- 
distended  vagina  gives  way,  in  which  case  the  laceration  occurs  in  a 
transverse  or  oblique  direction,  and  usually  upon  the  posterior  wall ; 
or  the  lower  segment  of  the  uterus  becomes  compressed  between  the 
child's  head  and  the  walls  of  the  pelvis,  and  a  thinning  and  bruising 
of  the  imprisoned  portion  take  place.  As  the  uterus  contracts,  its 
muscular  fibers  drag  upon  the  compressed  and  weakened  tissues  at 
the  fixed  points,  which  yield  finally  to  the  tractile  force,  and  rupture 
ensues. 

2.  If  the  pains  are  weak  or  fail  outright,  the  lower  segment  of  the 
uterus  remains  undilated  until  either  strong  pains  are  excited,  or  the 
mechanical  hindrance  is  so  far  removed  by  perforation  of  the  head  that 
the  weakened  pains  suffice  to  overcome  the  obstacle. 

Influence  of  the  Contracted  Pelvis  upon  the  Mechanism  of  Labor. — 
"When  the  pelvic  contraction  is  not  such  as  to  render  the  entrance  of 
the  head  impossible,  the  mechanism  of  labor  depends  not  only  upon 
the  size  and  shape  of  the  pelvic  space,  but  upon  the  siz«,  form,  com- 
pressibility and  position  of  the  child's  head.  If  a  small,  soft  head  has 
to  pass  through  a  pelvis  contracted  to  only  a  moderate  degree,  the 
mechanism  may  not  differ  from  that  of  a  normal  labor.  In  cases  of 
relatively  great  disproportion,  delivery  is  only  practicable  where  the 
position  of  the  head  is  favorable — i.  e.,  corresponds  in  each  case  to  the 
peculiar  shape  of  the  pelvis.  If  the  conditions  are  favorable,  and  the 
pains  are  of  normal  strength,  a  segment  of  the  head,  after  the  period 
of  dilatation  has  been  completed,  is  pressed  into  the  pelvis.  The  size 
of  the  segment  depends  upon  the  extent  of  the  resistance  offered,  and 
thus,  at  an  early  stage,  it  furnishes  us  a  notion  as  to  the  degree  of  dis- 
proportion existing.  As  labor  progresses,  the  cranial  bones  (Change  in 
shape  and  overlap  one  another,  so  that  the  head  gradually  becomes 
molded  to  the  contour  of  the  pelvic  ring.  When  the  largest  circum- 
ference of  the  child's  head  has  become  fixed  at  the  pelvic  strait,  as  the 
contraction  exists  for  the  most  part  at  the  brim,  the  difficulties  are 
usually  overcome  ;  and,  where  the  pains  continue  good,  the  remainder 
of  the  labor  is  accomplished  in  accordance  with  the  ordinary  mechan- 
ism. If  the  pains  fail,  or  the  contraction  continues  throughout  the 
entire  pelvic  canal,  artificial  aid  may  be  needed  even  after  the  brim  has 
been  passed. 

In  the  simple  flattened  pelvis  the  occipito-frontal  diameter  of  the 
head  engages  in  the  transverse  diameter  of  the  brim.  Even  when 
the  position  is  originally  oblique,  the  intermittent  contractions  of  the 
uterus  communicate  movements  to  the  smooth  surface  of  the  head, 
which  gradually  bring  its  long  diameter  into  correspondence  with  the 
long  diameter  of  the  flattened  pelvis.    The  head  enters  the  brim  with 


452 


THE  PATHOLOGY  OF  LABOR. 


its  posterior  surface  tilted  toward  the  shoulder,  the  anterior  parietal 
bone  presenting,  and  the  sagittal  suture  running  parallel  with,  and  in 
more  or  less  close  proximity  to,  the  promontory.  This  lateral  obliqui- 
ty, or  obliquity  of  Naegele  as  it  is  termed,  is  due  simply  to  the  fact 
that  the  narrowing  of  the  antero-posterior  diameter  prevents  both 
parietal  bones  from  entering  the  pelvis  upon  the  same  plane.  When 
the  broad  region  between  the  parietal  bosses  meets  with  the  resistance 
of  the  conjugate,  the  occipital  portion  of  the  head  glides  to  one  side, 
and  the  narrow  bitemporal  diameter  engages  in  the  contracted  space. 
In  this  position,  the  occiput  usually  rests  upon  the  linea  terminalis. 
Owing  to  the  resistance  offered  to  the  occiput,  the  forehead  sinks  into 
the  pelvis,  so  that  the  large  fontanelle  occupies  a  deeper  position  than 
the  posterior  one. 

Before  the  head  adapts  itself,  therefore,  to  the  pelvic  entrance,  the 
anterior  parietal  surface  rests  upon  the  symphysis,  while  the  posterior 
surface  is  impinged  upon  by  the  promontory  near  the  large  fontanelle. 
The  latter  is  felt  low  down,  near  the  median  line.  The  small  fonta- 
nelle, owing  to  the  dip  of  the  forehead,  is  occasionally  out  of  reach. 
Upon  the  side  of  the  pelvis  to  which  the  forehead  is  turned,  the  space 
is  incompletely  filled  out. 

The  adaptation  of  the  head  to  the  pelvic  brim  is  the  result  of  two 
combined  movements,  which  occur  nearly  simultaneously  : 

1.  The  symphysis  pubis  furnishes  a  pivot  around  which  the  head 
rotates  in  the  direction  of  the  fronto-occipital  diameter.  As  the  head 
is  pressed  into  the  pelvis  from  above,  the  posterior  parietal  bone  is 
flattened  by  the  projecting  promontory.  During  the  descent  the  dis- 
tance between  the  sagittal  suture  and  the  promontory  gradually  widens, 
and  the  former  approaches  the  median  line. 

2.  We  have  seen  that  the  head  entered  the  pelvis  at  first  with  a  deep 
position  of  the  anterior  fontanelle.  By  the  time,  however,  the  bitem- 
poral diameter  becomes  fairly  fixed  in  the  conjugate,  the  anterior  fon- 
tanelle moves  upward  and  forward  toward  the  side-wall  of  the  pelvis, 
while  the  small  fontanelle  sinks  downward,  and  occupies  a  position 
near  the  center  of  the  cavity.  This  movement  is  not  simply  a  crowd- 
ing of  the  entire  head  in  the  direction  of  the  brow,  but  is  due  to  a 
rotation  of  the  head  upon  an  axis  furnished  by  the  conjugate  diam- 
eter,* the  symphysis  and  the  promontory  furnishing  the  pivotal  points. 

By  the  time,  in  the  rotation  of  the  head  upon  its  fronto-occipital 
diameter,  the  posterior  boss  reaches  the  level  of  the  promontory,  the 
largest  circumference  of  the  child's  head  has  already  engaged  in  the 
straitened  brim,  and  the  influence  of  the  pelvic  flattening  upon  the 
mechanism  of  labor  ceases.  Then,  if  the  pains  continue  good,  the 
flexed  head  reaches  the  floor  of  the  pelvis,  the  occiput  rotates  to  the 
front,  and  delivery  is  accomplished  as  under  normal  conditions. 

*  LiTZMANN,  Volkmann's  "  SammL  klin.  Vortr.,"  No.  74,  p.  557. 


CONTRACTED  PELVES. 


453 


In  the  justo-minor  pelvis,  the  mechanism  of  labor  is  nearly  the 
reverse  of  that  described  in  the  flattened  form.  Thus,  as  a  rule, 
both  parietal  bones  engage  in  the  pelvic  brim  at  the  same  time — i.  e. , 
the  obliquity  of  Naegele  is  either  slightly  marked,  or  absent  altogether. 
Again,  the  head  may  enter  the  pelvis  in  any  of  its  diameters.  To  be 
sure,  the  oblique  diameter  is  the  one  it  usually  occupies.  Still,  Litz- 
mann  reports  two  cases  in  which  the  sagittal  suture  corresponded  to 
the  conjugate  diameter  from  the  outset  of  the  labor.*  In  the  early 
stages,  it  is  not  uncommon  for  the  head  to  oscillate  at  the  brim  for 
a  time  before  fixation  takes  place. 

Characteristic  of  transverse  narrowing  is  the  flexed  condition  of 
the  head  from  the  moment  it  begins  its  descent  into  the  pelvis.  In- 
deed, the  flexion  at  the  brim  equals  in  degree  that  which  usually  ob- 
tains only  at  the  pelvic  outlet.  The  small  fontanelle  occupies  the 
middle  point  of  the  pelvic  space,  the  neck  rests  upon  the  linea  termi- 
nalis,  the  anterior  portion  of  the  head  and  brow  are  pressed  against 
the  opposite  pelvic  walls,  the  long  diameter  of  the  head  (from  chin  to 
vertex)  lies  in  the  axis  of  the  pelvis,  and  the  face  looks  upward  toward 
the  fundus  uteri.  If  the  transverse  narrowing  continues  toward  the 
outlet,  the  extreme  flexion  is  maintained  after  the  brow  has  passed 
below  the  level  of  the  promontory.  In  such  cases  it  may  even  happen 
that  the  small  fontanelle  may  make  its  appearance  at  the  frenulum 
in  place  of  turning  under  the  arch  of  the  pubes.  Sometimes  the  head 
gets  fairly  impacted  in  the  pelvis,  and  further  advance  is  rendered  im- 
possible. AYhen  the  pelvis  widens  below  the  brim,  the  small  fontanelle 
noticeably  leaves  little  by  little  its  central  position. 

In  the  generally  contracted,  flattened  pelvis,  the  mechanism  of 
labor  is  influenced  by  both  the  antero-posterior  and  transverse  short- 
ening. As  in  flattened  pelves,  the  head  usually  occupies  the  transverse 
diameter,  and  the  sagittal  suture  looks  backward  toward  the  promon- 
tory. Before  the  head  becomes  fixed,  it  often  balances  at  the  conju- 
gate, rocking  to  and  fro,  as  the  uterus  falls  from  the  one  side  to  the 
other.  For  a  time,  therefore,  the  position  of  the  fontanelles  varies 
with  that  of  the  woman.  If,  however,  the  disproportion  is  not  abso- 
lute, and  the  pains  suffice  finally  to  fix  the  head,  the  latter  usually 
becomes  strongly  flexed,  and  the  occiput  descends  first  into  the  pelvis. 

When  the  head  does  not  enter  the  contracted  pelvis  in  an  advan- 
tageous position,  and  the  fault  is  not  rectified  either  by  the  hand  or 
the  action  of  the  labor-pains,  delivery  of  the  child  without  perforation 
often  becomes  impossible.  The  most  dangerous  of  these  faulty  posi- 
tions are  : 

1.  Cases  in  which  the  lateral  obliquity  of  Naegele  is  exaggerated, 
so  that  the  presenting  part  is  formed  by  the  anterior  parietal  bone. 
The  more  striking  forms  usually  occur  in  pelves  with  an  extremely 

*  LiTZMANN,  Volkmann's  "  Samml.  klin.  Vortr,,"  No.  74,  p.  545. 


454 


THE  PATHOLOGY  OF  LABOR. 


narrow  conjugate  and  a  high  promontory.  The  former  maintains 
the  head  high  above  the  brim,  while  the  latter  imparts  to  the  uterus 
a  posterior  concavity.  As  the  uterine  curve  is  followed  by  the  axis  of 
the  foetus,  the  head  is  strongly  bent  toward  the  posterior  shoulder. 
Sometimes  in  presentations  of  the  anterior  parietal  bone  the  sagittal 
suture  lies  above  the  promontory,  and  an  ear  can  be  felt  just  behind 
the  symphysis. 

2.  Cases  in  which  the  pelvic  brim  is  covered  by  the  posterior  pari- 
etal bone.  The  sagittal  suture  is  then  directed  to  the  front,  some- 
times lying  even  above  the  superior  border  of  the  anterior  pelvic  wall. 
Near  the  promontory  the  squamous  suture,  and  at  times  the  ear,  can 
be  felt.  This  peculiarity  is  rare  in  other  forms  of  contracted  pelves, 
but  occurs  as  often  as  once  in  five  times  (Litzmann)  in  flattened  pel- 
ves with  coincident  shortening  of  the  transverse  diameter. 

3.  In  cases  of  well-marked  kidney-shaped  pelves,  the  head  may 
engage  in  one  side  of  the  pelvis  only.  The  occiput  then  enters  usually 
the  side  of  the  brim  to  which  the  back  of  the  child  is  turned. 

4.  Brow  and  face  presentations  are  simply  exaggerations  of  the 
anterior  dip  of  the  head,  which  we  have  seen  is  the  normal  mode  of 
descent  during  the  early  stage  of  labor  in  flattened  pelves.  Although 
not  peculiar  to  contracted  pelves,  they  should  always,  when  present, 
lead  to  careful  measurements  of  the  pelvic  diameters.  They  increase 
the  difficulties  of  delivery,  not  only  because  of  the  unfavorable  rela- 
tions of  the  diameters  of  the  head  to  those  of  the  pelvis,  but  because 
the  pelvic  deformity  interferes  with  the  proper  rotation  of  the  chin 
and  forehead  forward  under  the  arch  of  the  pubes. 

In  breech  presentations,  the  delivery  of  the  trunk  takes  place  in 
accordance  with  the  ordinary  mechanism  in  the  normal  pelvis.  The 
arms,  however,  are  more  liable  to  be  reflected  to  the  sides  of  the  head. 

In  flattened  pelves  the  after-coming  head  enters  the  brim  in  the 
transverse  diameter.  The  position  of  the  chin,  where  the  transverse 
space  is  ample,  varies  with  the  degree  of  conjugate  shortening.  Where 
the  latter  is  only  of  moderate  extent,  the  ordinary  flexion  of  the  head 
may  not  be  interfered  with.  If,  however,  the  disproportion  between  the 
head  and  pelvic  diameters  is  considerable,  partial  extension  takes  place. 
In  cases  of  extreme  contraction  the  entire  head  may  be  retained  at 
the  brim.  The  chin  is  then  usually  turned  forward  so  as  to  rest  upon 
one  of  the  pubic  rami,  while  chin  and  occiput  occupy  nearly  the  same 
level. 

In  breech  deliveries,  the  mechanism  of  the  head's  passage  through 
simple  flattened  pelves  varies  as  the  head  engages  in  a  state  of  flexion 
or  extension.  In  the  former  case,  while  the  anterior  parietal  bone 
moves  downward  over  the  symphysis,  the  transit-line  marked  by  the 
promontory  upon  the  posterior  parietal  bone  runs  from  its  anterior 
inferior  angle,  just  in  front  of  the  ear,  in  an  oblique  direction  upward 


CONTRACTED  PELVES. 


455 


toward  the  parietal  boss.  When,  however,  the  head  enters  the  pelvis 
in  a  state  of  partial  extension,  a  furrow  is  formed  by  the  promontory, 
which  runs  nearly  parallel  to  the  coronal  suture.  If,  finally,  the  ex- 
tension is  complete,  and  the  occiput  descends  first  into  the  pelvis, 
the  marking  of  the  promontory  is  found  between  the  boss  and  the 
lambdoidal  suture. 

In  pelves  contracted  in  the  transverse  diameter,  extension  of  the 
chin,  unless  the  contraction  be  slight,  proves  an  insuperable  obstacle 
to  delivery.  Flexion,  however,  is  the  rule,  as  the  resistance  which  the 
occiput  meets  with  from  the  walls  of  the  pelvis  tends  to  direct  the 
chin  toward  the  chest. 

The  Effects  produced  in  Contracted  Pelvis  by  the  Pressure  of  the 
Child  upon  the  Soft  Maternal  Tissues. — The  body  of  the  child  rarely, 
and  only  in  cases  of  extreme  prolongation  of  the  expulsive  period, 
leaves  any  traces  upon  the  maternal  soft  parts.  Injurious  pressure 
proceeds  almost  exclusively  from  the  child's  head.  As  the  intra-pel- 
vic  organs  sustain  excessive  pressure  when  of  short  continuance  more 
easily  than  that  which  is  moderate  but  prolonged,  the  most  striking 
lesions  are  produced  in  head  presentations.  The  after-coming  head 
usually  passes  through  the  pelvis  too  rapidly  to  produce  any  pro- 
nounced effects.  The  pressure  is,  as  a  rule,  most  marked  at  the  brim, 
where,  as  we  have  seen,  the  contraction  is  in  the  generality  of  cases 
greatest,  and  w^here  the  pelvic  canal  is  most  encroached  upon  by 
sharp  projections.  The  pressure  may  be  either  diffused  over  the  entire 
periphery  of  the  brim,  or  it  may  be  more  localized  at  certain  definite 
points. 

Diffused  pressure  occurs  in  justo-minor  pelves,  or  where  complete 
accommodation  of  the  child's  head  to  the  form  of  the  pelvis  takes 
place.  It  gives  rise  to  disturbed  circulation  in  the  hypogastric  veins, 
and  as  a  further  consequence  to  transudation  of  serum,  and  capillary 
haemorrhages  in  the  tissues  of  the  cervix,  the  vaginal  walls,  and  exter- 
nal organs  of  generation. 

Circumscribed  pressure  leads  to  crushing,  thinning,  and  at  times  to 
the  complete  destruction  of  the  tissues  acted  upon,  the  extent  of  the 
lesion  depending  upon  the  intensity  and  duration  of  the  force  exerted. 
Usually  the  destructive  action  proceeds,  following  the  direction  of  the 
pressure  from  within  outward — i.  e.,  the  injuries  are  more  consider- 
able, both  in  degree  and  extent,  in  the  tissues  next  to  the  child's  head 
than  in  the  deeper  ones  contiguous  to  the  pelvic  border.  Complete 
perforation  of  the  tissues  during  labor  is  rare.  Perforation  is  com- 
monly the  result  of  necrosis,  the  sloughing  of  the  compressed  tissues 
taking  place  during  the  puerperal  period. 

The  pressure  from  the  promontory  is  brought  to  bear  always  upon 
the  cervix  uteri.*    The  supra- vaginal  portion  is  more  commonly 

*  LiTZMANN,  Volkmann's  "Samml.  klin.  Vortr.,"  No.  23,  p.  186. 


456  THE  PATHOLOGY  OF  LABOR. 

affected  than  the  vaginal  portion.  The  consequent  loss  of  substance 
is  of  a  funnel  shape,  starting  from  the  inner  surface,  and  rarely  pene- 
trating through  the  peritonaeum.  The  coverings  of  the  promontory 
are  not  affected  by  pressure. 

Pressure  from  the  upper  border  of  the  symphysis  pubis  usually 
affects  the  vaginal  wall  and  the  adjacent  tissues  of  the  bladder.  Fis- 
tulse  resulting  are,  therefore,  much  more  commonly  vesico-vaginal 
than  utero-vesical.  Here,  too,  the  lesions  are  more  extensive  upon 
the  inner  surface  of  the  utero-vaginal  canal,  and  diminish  as  they 
extend  outward.  Thus,  the  destruction  of  tissue  is  greatest  upon  the 
cervical  and  vaginal  walls,  is  less  marked  upon  the  posterior  bladder- 
wall,  while  the  anterior  wall  exhibits  only  faint  traces  of  injury. 

Pressure  from  the  lateral  walls,  and  from  the  horizonal  rami  of  the 
pubes,  occurs  most  frequently  in  faulty  positions  of  the  child's  head. 
Thus,  in  brow  presentations,  the  intervening  tissues  are  apt  to  become 
clamped  between  the  occiput  and  the  margin  of  the  side-wall.  Again, 
when  the  sagittal  suture  is  directed  to  the  front,  and  the  posterior 
parietal  bone  presents,  a  similar  compression  may  take  place  between 
the  anterior  wall  and  the  child's  head.  Sharp  bony  projections  from 
the  crests  of  the  pubes  are  commonly  covered  by  the  tendinous  attach- 
ments of  the  psoas  minor  muscles.  In  case  of  long-continued  labor, 
however,  the  spinous  outgrowths  and  sharp  edges  of  the  crests  are 
liable  to  rub  through  their  protective  coverings,  and  secondarily  the 
utero-vaginal  tissues. 

Influence  of  the  Pressure  of  the  Pelvis  upon  the  Integuments  of  the 
Child's  Head. — One  of  the  commonest  results  of  the  peripheral  pressure 
of  the  brim  upon  the  child's  head  is  the  production  of  the  scalp-tumor. 
Its  formation  is  usually  associated  with  compression  of  the  cranial 
bones.  As  the  bones  overlap,  the  integuments  of  the  engaged  portion 
of  the  head  are  thrown  into  folds.  As,  however,  in  consequence  of 
the  obstruction  in  the  venous  circulation,  transudation  of  serum  takes 
place  into  the  subcutaneous  cellular  tissue,  the  folds  subsequently  dis- 
appear, and  a  swelling  ensues.  It  will  be  seen  that  conditions  favor- 
able to  the  production  of  the  scalp-tumor  are  a  soft,  easily  molded 
head,  and  such  degree  of  transverse  pelvic  contraction  as  serves  to 
render  the  circular  pressure  of  the  scalp  complete.  Owing  to  the  lat- 
ter condition,  the  scalp-tumor  is  found  more  frequently  and  more  de- 
veloped in  justo-minor  and  generally  contracted,  flattened  pelves  than 
in  simple  flattened  pelves  with  normal  transverse  dimensions.  Usually 
the  tumor  does  not  form  until  after  rupture  of  the  membranes.  At 
times,  however,  in  justo-minor  pelves  the  head  may  become  so  fixed 
at  the  brim  during  the  first  stage  of  labor  that  a  diffused  swelling  of 
the  scalp  may  follow  while  the  membranes  are  still  intact.  A  scalp- 
tumor  at  the  brim  is  of  favorable  import.  It  shows  that  the  pains  are 
good.    So  long  as  the  tumor  continues  to  increase,  if  the  presentation 


CONTRACTED  PELVES. 


457 


is  favorable,  the  accommodation  of  the  head  remains  a  possibility. 
The  increase  of  the  tumor  serves,  too,  to  fix  the  head  at  the  brim,  and 
favors  the  overlapping  of  the  cranial  bones.  It  likewise  gives  to  the 
head  the  form  of  an  elongated  ellipse,  a  form  most  favorable  to  its 
passage  through  the  contracted  pelvic  canal. 

Localized  pressure-marks  upon  the  child's  head  are  derived,  in  the 
great  majority  of  cases,  from  contact  with  the  promontory.  With  less 
frequency  they  have  their  origin  in  pressure  produced  by  the  anterior 
!ind  lateral  pelvic  walls  and  the  inward  projection,  in  rachitic  pelves, 
of  the  cartilage  at  the  symphysis  pubis.  They  consist  of  round  and 
oval  spots  and  reddened  lines,  which  disappear  in  the  lighter  cases 
usually  in  from  twelve  to  twenty-four  hours.  If  the  pressure  has  been 
long  continued,  it  may  give  rise  to  ul- 
ceration, or  even  to  complete  destruction 
of  the  skin  down  to  the  periosteum. 
While  not  usually  dangerous  to  the 
child,  in  exceptional  cases  they  may  be- 
come the  starting-point  of  supjDuration 
in  the  surrounding  subcutaneous  cellu- 
lar tissue,  and  thus  lead  to  fatal  pyaemia. 
They  are  found  with  greatest  frequency 
upon  the  parietal  bones,  especially  upon 
the  posterior  one.    More  rarely  they  are 

situated  upon  the  frontal,  and  in  very  rare  instances,  finally,  upon  the 
occipital  and  temporal  bones.  The  situation  and  direction  of  the  red 
lines  depend  chiefly  upon  the  manner  in  which  the  head  enters  the 
pelvis.  Thus,  in  simple  flattened  pelves,  where  moderate  extension 
occurs  in  the  normal  mechanism  of  labor,  the  mark  of  the  promon- 
tory runs  along  the  posterior  parietal  bone,  between  the  boss  and  the 
large  fontanelle,  either  parallel  to  the  coronal  suture,  or  at  first  in  the 
direction  of  the  boss,  and  then  later  as  flexion  occurs  forward  toward 
the  frontal  bone  (Dohrn).  In  cases  where  transverse  shortening  causes 
flexion  of  the  head  at  the  brim,  the  principal  point  of  pressure  lies 
near  the  parietal  boss,  and  the  line  runs  obliquely  forward  toward  the 
outer  angle  of  the  eye,  or  toward  the  cheek,  according  to  the  extent 
of  the  flexion.  Sometimes  a  red  line,  running  across  the  forehead 
nearly  parallel  to  the  coronal  suture,  is  produced  by  the  pressure  of 
the  side-wall. 

Pressure  upon  the  ophthalmic  vein,  when  it  occurs,  leads  to  (Edem- 
atous swelling  and  hyperaemia  of  the  lid,  and  to  increased  secretion 
from  the  conjunctiva. 

Influence  of  the  Pressure  of  the  Pelvis  upon  the  Cranial  Bones. — 
The  so-called  molding  of  the  child's  head,  by  which  it  is  made  to  con- 
form to  the  size  and  shape  of  the  pelvis,  is  chiefly  effected  by  the  dis- 
placements and  alterations  in  the  form  of  the  cranial  bones.    Of  the 


458 


THE  PATHOLOGY  OF  LABOR. 


displacements,  the  most  important  consists  in  the  overriding  of  the 
bones  at  the  principal  sutures.  The  most  common  site  is  along  the 
sagittal  suture.  Usually  the  posterior  parietal  bone  is  flattened  and 
depressed  beneath  its  fellow.  At  the  same  time  the  curvature  of  the 
anterior  or  presenting  parietal  bone  is  increased.  In  transverse  nar- 
rowing, the  occipital  bone  is  depressed  along  the  lambdoidal  suture. 
The  position  of  the  frontal  bones  at  the  coronal  suture  is  subject  to  a 
variety  of  influences.  As  a  rule,  however,  they  are  depressed  beneath 
the  parietal  bones.  Overlapping  often  does  not  extend  the  entire 
length  of  a  suture,  but  may  exist  in  one  part,  while  in  another  the 
bones  may  occupy  the  same  level.  Sometimes  a  displacement  takes 
place  between  the  two  lateral  halves  of  the  head  in  the  direction  of 
the  occipito-frontal  diameter.  This  movement  is  supposed  to  be  due 
to  the  influence  of  the  promontory,  which  pushes  the  posterior  half 
forward  when  the  head  is  flexed,  and  backward  in  cases  of  partial 
extension. 

The  compression  to  which  the  child's  head  is  subjected,  when  pro- 
longed and  excessive,  is  apt  to  produce  disturbed  cranial  circulation. 
Eupture  of  the  capillaries  which  pass  from  the  surface  of  the  brain  to 
the  arachnoid  sac,  and  to  the  sinuses  of  the  dura  mater,  may  give  rise 
to  intra-cranial  extravasations.  The  overriding  at  the  sagittal  suture, 
in  extreme  cases,  may  cause  laceration  of  the  sinus  longitudinalis. 
Separation  of  the  bones  at  the  sagittal  and  coronal  sutures  sometimes 
takes  place  while  the  coverings  of  the  skull  remain  intact.* 

In  a  small  percentage  of  cases  (7*3  per  cent.,  Litzmann)  furrow-like 
depressions  occur.  The  usual  site  is  along  the  line  of  the  coronal 
suture,  where  they  are  formed  by  the  promontory.  In  front  a  grooved 
line  is  sometimes  found  near  the  squamous  suture,  produced  by  the 
pressure  of  the  anterior  pelvic  wall.  Triangular  depressions  (the 
spoon-shaped  depressions  of  Michaelis)  situated  upon  the  posterior 
parietal  bone,  between  the  boss  and  the  large  fontanelle,  are  of  still 
rarer  occurrence.  They  are  found  chiefly  upon  the  heads  of  prema- 
ture children,  where  they  are  of  sinister  import.  Actual  fracture  of 
the  skull  in  head  presentations  is  extremely  infrequent,  and  is  gener- 
ally due  to  the  employment  of  the  forceps. 

In  breech  presentations,  lesions  of  the  scalp,  owing  to  the  shortness 
of  the  time  to  which  the  after-coming  head  is  subject  to  the  pressure 
of  the  contracted  pelvis,  are,  in  two  thirds  of  the  cases,  absent  alto- 
gether. When  they  are  present  they  are  comparatively  trivial,  con- 
sisting of  slight  swelling  of  the  integuments,  and  now  and  then  of  a 
red  mark  left  by  the  promontory.  The  cranial  bones,  on  the  con- 
trary, when  rapidly  dragged  by  the  projecting  promontory,  are  pecul- 
iarly liable  to  serious  injury.  Thus,  in  breech  cases,  depressions,  fract- 
ures, and  fissures  of  the  parietal  bones,  are  much  more  common  than 
♦Litzmann,  Volkmann's  "Samml.  klin.  Vortr.,"  No.  23,  p.  191. 


CONTKACTED  PELVES.  459 

iu  head  presentations.  Forcible  tractions  upon  the  trunk  sometimes 
lead  too  to  a  rupture  of  the  squamous  sutures,  or  even  to  separation  of 
the  condyles  from  the  occipital  bones.* 

Prognosis  in  Contracted  Pelves. — The  mortality  to  the  mother  is  at 
least  twice  as  great  as  in  normal  pelves.  The  causes  of  this  increased 
death-rate  are  to  be  found  in  the  concurrent  action  of  a  great  variety 
of  influences.  Among  the  chief  of  these  is  the  jorolonged  labor,  an 
event  which  under  all  circumstances,  especially  after  the  rupture  of 
the  membranes,  tends  to  diminish  the  chances  of  recovery.  This  re- 
sult is  due  to  the  strain  upon  the  nervous  system  from  the  protracted 
duration  of  the  associated  pain,  to  the  depression  of  the  vital  powers 
growing  out  of  the  fasting  and  loss  of  sleep  which  labor  entails,  to  the 
irritation  and  crushing  of  the  soft  parts,  and,  finally,  to  decomposition 
of  the  fluids  retained  within  the  uterine  cavity  in  cases  where  access 
of  air  has  taken  place.  In  contracted  pelves  we  have  superadded  to 
these  general  sources  of  disturbance  the  special  injurious  effects  pro- 
duced by  the  pressure  of  the  lower  segment  of  the  uterus,  the  vagina 
and  the  soft  parts  which  cover  the  cavity  of  the  small  pelvis  between 
the  hard  head  of  the  child  and  the  bony  walls.  As  the  results  of 
pressure,  we  have  seen  that  obstruction  to  the  venous  circulation, 
oedema,  capillary  haemorrhages,  superficial  lacerations  of  the  mucous 
membrane,  and  at  localized  points  necrosis  and  even  complete  separa- 
tion of  the  interposed  tissue  may  take  place.  These  further  lead  to 
metritis,  endometritis,  parametritis,  and  perimetritis,  which  are  an- 
nounced at  times  during  labor,  but  more  commonly  subsequent  to 
confinement,  by  sharp  elevations  of  temperature.  When  the  destruc- 
tion of  tissue  reaches  the  peritonaeum,  general  peritonitis  follows,  as 
a  rule.  When  the  necrosed  tissues  become  gangrenous  from  access 
of  air,  the  septic  poisons  generated  spread  through  the  cellular  tissue, 
and  lead  speedily  to  a  fatal  termination.  Sometimes  shock  destroys 
the  patient  during  the  first  day  or  two  following  labor,  before  local  in- 
flammations have  had  time  to  develop.  Further  dangers  to  be  appre- 
hended are  rupture  of  the  uterus  and  the  pelvic  articulations,  fistulous 
communications  with  the  bladder  and  the  rectum,  injuries  to  nerves 
of  the  ischiatic  plexus,  post-partum  haemorrhage  as  a  consequence  of 
uterine  exhaustion,  and  thrombus  formation  in  the  veins  of  the  uter- 
ine parenchyma.  Even  the  operative  measures  resorted  to  for  the 
relief  of  the  patients  are  often  new  sources  of  peril,  and  their  employ- 
ment is  to  be  regared  simply  as  a  lesser  evil. 

For  the  child  the  action  of  the  contracted  pelvis  is  even  more  del- 
eterious, f     The  infant  mortality,  in  cases  not  requiring  sacrificial 

*  C.  RuGE,  "  Verletzung  des  Kindes  durch  Extraction  bei  Bcckenlage,"  "  Ztschr.  f. 
Geburtsh.,"  Bd.  i,  p.  74. 

f  Spiegelberg  puts  the  mortality  of  the  children  at  thirty-five  per  cent,  {vide  "  Lehr- 
buch  der  Geburtshiilfe,"  p.  464). 


460 


THE  PATHOLOGY  OF  LABOR. 


operations,  is  explained  by  the  long  duration  of  the  labor,  and  the 
prevalence  of  faulty  presentations  and  positions.  In  the  majority  of 
instances  death  takes  place  from  asphyxia  promoted  by  the  early  rupt- 
ure of  the  membranes,  the  complete  escape  of  the  amniotic  fluid,  the 
prolapse  of  the  cord,  the  disturbances  in  the  utero-placental  circula- 
tion resulting  from  the  retraction  of  the  uterus  upon  the  surface  of 
the  child's  body,  and  sometimes  by  the  premature  separation  of  the 
placenta.  The  prognosis  for  the  child  is  especially  unfavorable  in 
premature  labors.  This  arises  not  alone  from  the  increased  frequency 
of  malpresentations,  but  from  the  diminished  power  of  premature 
children  to  resist  external  ]3ressure.  Thus,  death  may  take  place  from 
direct  pressure  upon  the  medulla  oblongata  through  the  thin  bony 
coverings  of  the  head,  or  extensive  cerebro-spinal  effusions  of  blood 
may  result  from  the  laceration  of  the  delicate  walls  of  the  intra-cranial 
and  intra-spinal  vessels. 


CHAPTER  XXVI. 

TREATMENT  OF  CONTRACTED  PELVES. 

Cases  of  extreme  pelvic  contraction,  rendering  delivery  per  vias  naturales  impossible. — 
Cases  indicating  craniotomy  or  premature  labor, — Cases  where  extraction  of  a  living 
child  at  terra  is  possible. — Premature  labor. — Version. — Forceps. — Expectant  treat- 
ment. 

The  resources  at  the  disposition  of  the  accoucheur,  in  cases  of  con- 
tracted pelvis  requiring  obstetrical  aid,  are  the  Caesarean  section,  the 
induction  of  premature  labor,  craniotomy,  forceps,  and  version.  But, 
before  it  is  possible  to  form  an  opinion  regarding  the  treatment  best 
suited  to  an  individual  case,  it  is  necessary  to  first  obtain  a  clear  and 
definite  idea  regarding  the  degree  and  character  of  the  pelvic  deform- 
ity. We  have,  then,  to  settle  the  following  questions  :  Has  pregnancy 
advanced  to  term  ?  If  not,  does  the  case  call  for  the  induction  of 
abortion  or  premature  labor  ?  If  the  end  of  utero-gestation  has  been 
reached,  is  it  possible  to  deliver  the  child  through  the  natural  passages  ? 
Is  the  child  living  or  dead  ?  If  the  former,  do  the  interests  of  the 
mother  require  the  sacrifice  of  the  child's  life  ?  If  the  conditions  are 
such  as  not  to  render  it  impossible  for  a  living  child  to  be  born,  in 
what  way  can  we  best  subserve  the  interests  of  both  mother  and  child  ? 
The  right  choice  of  measures  requires  not  only  an  accurate  apprecia- 
tion of  the  advantages,  limitations,  and  drawbacks  which  inhere  to  the 
measures  themselves,  but  the  extent  to  which  the  mechanical  obsta- 
cles to  delivery  are  heightened  or  modified  by  those  remoter  influences 
which  we  have  seen  are  exerted  upon  the  organic  processes  of  labor  by 
the  pelvic  contraction. 


TREATMENT  OF  CONTRACTED  PELVES. 


461 


The  greater  the  degree  .of  pelvic  narrowing,  however,  the  more  de- 
cided the  influence  of  the  pelvis  becomes,  and  the  more  definite,  there- 
fore, the  treatment. 

For  the  sake  of  convenience  it  is  customary  to  consider  apart  the 
following  classes  :  * 

1.  Cases  of  such  extreme  pelvic  contraction  that  the  attempt  to  de- 
liver the  child  through  the  natural  passages  is  inadvisaUe.  In  these 
extreme  degrees  of  pelvic  deformity  premature  labor  holds  out  no  hope 
of  saving  the  life  of  the  child,  and  affords  but  a  trifling  advantage  to 
the  mother.  If  abortion  is  not  produced  in  the  early  months,  the  only 
resource  is  the  Csesarean  section  or  laparo-elytrotomy.  The  precise 
limit  at  which  the  dangers  from  delivery  through  the  pelvis  rise  to  the 
level  of  or  exceed  those  from  the  Caesarean  section  is  not  easy  to  deter- 
mine. It  depends  partly  upon  the  size  and  ossification  of  the  child's 
head,  and  largely  upon  the  experience  and  dexterity  of  the  operator. 

^Eichaelis,  in  the  case  of  a  dwarf  scarcely  three  and  a  half  feet 
high,  extracted  a  small  child  through  a  pelvis  measuring  but  one 
inch  and  a  half  in  the  conjugate  diameter. f  The  operation  lasted 
two  and  a  half  hours.  At  the  end  of  two  weeks  the  patient  was  able 
to  resume  her  household  duties.  Dr.  Osborn,  in  the  celebrated  case 
of  Elizabeth  Sherwood,  extracted  a  child  through  a  pelvis  measur- 
ing, as  he  believed,  but  three  quarters  of  an  inch  in  its  narrowest 
portion  !  Barnes  X  extracted  with  perfect  success  a  child  through  a 
conjugate  which,  he  says,  certainly  did  not  exceed  one  inch  and  a 
half.  It  would  be  easy  to  go  on  and  extend  this  list,  to  show  that 
there  is  no  degree  of  conjugate  shortening  that  renders  it  utterly  im- 
possible to  extract  a  mutilated  child.  But  the  question  which  we  should 
ask  for  our  guidance  is,  not  what  can  possibly  be  accomplished  by  the 
skill  and  ingenuity  of  the  exceptionally  experienced  operator,  who  is 
capable  of  making  whatever  rules  he  likes  to  govern  his  own  actions, 
but  what  is  the  point  at  which  men  in  every-day  practice  need  expect 
to  find  the  dangers  from  craniotomy  and  the  Caesarean  section  rise 
to  nearly  the  same  level.  Dr.  Parry  collected  seventy  cases  of  cranioto- 
my in  pelves  measuring  two  and  a  half  inches  and  under.  Seven  had 
to  be  terminated,  finally,  by  Caesarean  section.  Of  the  seventy  women 
forty-three  survived,  and  twenty-seven  died.  The  work  was  not  done  by 
tyros,  but  by  celebrated  obstetric  surgeons.  Thus,  the  best  results  of 
the  ablest  accoucheurs  show  a  mortality  from  craniotomy,  in  the  higher 
degrees  of  pelvic  deformity,  of  nearly  forty  per  cent.  In  the  hands  of 
an  operator  of  limited  experience,  I  believe  the  Caesarean  section,  when 
timely  made,  offers  ordinarily  to  the  mother  a  better  chance  of  recov- 

*  The  limits  are  those  of  Litzmann.  Vide  "  Ueber  die  Behandlung  der  engen  Beck- 
en,"  Volkmann's  "  Samml.  klin.  Vortr.,"  No.  90. 

f  MicHAELis,  "  Abhandlungen  aus  dem  Gebiete  der  Geburtshiilfe,"  p.  151.  The  op- 
eration lasted  two  and  a  half  hours.  %  Barnes,  "  Obstetric  Operations,"  p.  406. 


462 


THE  PATHOLOGY  OF  LABOR. 


ery.  There  are,  of  course,  exceptions  to  the- rule.  Most  pelves  measur- 
ing less  than  two  and  a  half  inches  in  the  conjugate  belong  to  the 
category  of  generally  contracted  flattened  pelves.  Where,  exception- 
ally, the  transverse  diameter  is  not  materially  diminished,  the  difiicul- 
ties  of  craniotomy  are  greatly  lessened,  and,  if  at  the  same  time  the 
child's  head  be  soft  and  compressible,  a  comparatively  easy  extraction 
may  give  rise  to  false  ideas  concerning  the  real  dangers  of  delivery  by 
the  natural  passages.  These  are  due  chiefly  to  the  fact  that  the  opera- 
tion has  to  be  carried  on  within  the  uterine  cavity,  when,  owing  to 
the  contracted  brim,  no  descent  of  the  head  is  possible.  A  long  op- 
eration conducted  within  the  uterine  cavity  is  always  fraught  with  evil. 

The  dangers  are  not  altogether  mechanical.  Even  if  serious  lesions, 
such  as  perforations,  rupture  of  the  uterus,  and  lacerated  wounds,  are 
avoided,  some  contusion  of  the  lower  uterine  segment  is  inevitable,  air 
enters  freely  the  uterine  cavity,  the  patient  exhibits  very  commonly 
the  symptoms  of  profound  shock,  and  the  delivery  is  often  followed  by 
post-partum  haemorrhage,  due  to  uterine  inertia.  The  means  employed 
to  check  haemorrhage  tend  still  further  to  depress  the  vital  powers.  In 
many  cases  the  uterus  remains  large,  and  the  labor  is  followed  by  ca- 
tarrhal endometritis.  This  ordinarily  mild  puerperal  atfection  is  apt, 
owing  to  the  introduction  of  air  and  the  presence  of  bits  of  necrosed 
tissue,  to  assume  a  septic  form,  and  pave  the  way  to  a  fatal  termination. 

The  contiguity  of  the  peritonaeum  likewise  adds  to  the  formidable 
character  of  all  supra-pelvic  operations.  When  the  outlet  of  the  pel- 
vis alone  is  contracted,  and  craniotomy  can  be  performed  upon  the 
head  after  it  has  entered  the  vaginal  canal,  the  dangers  of  extraction 
are  much  diminished. 

Cases  of  extreme  degrees  of  the  justo-minor  pelvis  are  believed  to  be  exces- 
sively rare.  Certainly  the  whole  number  reported  since  Naegele's  day  may  be 
easily  counted  on  the  fingers  of  the  two  hands.  At  full  term  the  labor  takes 
place,  provided  the  general  contraction  is  such  as  to  retain  the  head  at  the  brim, 
in  one  of  two  ways  : 

1.  The  uterus  retracts  up  over  the  head  of  the  child.  If  the  head  does  not 
descend,  the  vagina  is  drawn  upward  and  is  exposed  to  injurious  tension.  Should 
notliing  be  done  to  relieve  this  condition,  the  thin  vagina  is  liable  to  be  rubbed 
through  by  the  pressure  it  encounters  at  the  brim,  and  especially  at  the  symphy- 
sis pubis.  Version  would  here  be  impossible,  and  the  forceps  would  only  enhance 
the  risks.  Perforation  and  decerebration  would  at  once  diminish  the  pressure. 
With  little  over  three  inches  in  the  conjugate  and  four  in  the  transverse  diame- 
ter, the  vault  of  the  skull  may  be  broken  up  with  the  cranioclast,  the  chin  tilted 
downward,  and  the  head  brought  edgewise  through  the  pelvis.  In  this  way, 
with  moderate  skill,  it  would  be  possible  to  extract  a  dead  child.  The  operation 
of  laparo-elytrotomy,  however,  seems  so  peculiarly  fitted  to  these  conditions, 
that  it  deserves  a  trial  in  the  interest  of  both  mother  and  child. 

2,  The  membranes  rupture  early,  the  waters  gradually  escape,  and,  as  the 
head  does  not  descend,  the  uterus  retracts  down  firmly  upon  the  child.  A  scalp- 


TREATMENT  OF  CONTRxVCTED  PELVES. 


463 


tumor  forms,  which  fixes  the  head  at  the  brim  and  pushes  the  cervix  and  lower 
segment  of  the  uterus  before  it.  Here  it  would  be  proper  to  await  for  a  time 
the  results  of  uterine  action.  As  the  transverse  diameter  can  only  be  roughly 
estimated,  the  head  may  lengthen  out  and  adapt  itself  to  the  pelvic  canal.  But 
the  delay  should  not  be  too  prolonged.  If,  in  spite  of  the  formation  of  the  scalp- 
tumor,  the  hony  head  remains  unmoved  at  the  brim,  it  is  a  question  whether  it 
would  not  be  the  wiser  plan  to  proceed  at  once  to  the  Csesarean  section. 

Naegele  *  reports  the  history  of  a  dwarf  whose  pelvis  measured  but  three 
inches  and  seven  lines  in  the  transverse  and  three  inches  in  the  conjugate.  He 
dehvered  her  with  forceps  of  a  tive-and-a-half-pound  child,  but  she  died  on  the 
tenth  day.  Heim  reports  the  history  of  a  dwarf  with  three  and  a  quarter  inches 
conjugate,  and  four  and  three  quarters  inches  transverse  diameter.  Delivery  by 
perforation  and  forceps.    Kupture  of  the  three  articulations.! 

Spiegelberg  reports  a  case  with  nearly  the  same  dimensions.  Child  presented 
by  the  breech.  Extraction  difficult.  Perforation  of  after-coming  head.  Ceph- 
alotripsy.  The  patient  died  shortly  after  delivery,]:  I  have  reported  a  case 
where  the  conjugate  was  three  and  one  sixth  inches,  and  the  transverse  four  and 
a  half  inches.  Delivery  by  perforation,  the  cranioclast,  and  the  crotchet.  The 
patient  died  on  the  third  day  ("Trans,  of  the  Am.  Gynaec.  Soc,"  vol.  iv).  Kor- 
mann  relates  a  case  nearly  identical  with  my  own,  both  as  regards  its  diameters 
and  the  existence  of  a  slight  lateral  obliquity.  After  over  three  days'  labor  the 
head  adapted  itself  to  the  pelvis,  and  the  child  was  extracted  alive  by  forceps. 
The  mother  died  of  peritonitis.* 

Thus,  of  five  women  with  generally  contracted  pelves,  in  which  the  conju- 
gate ranged  from  three  to  three  and  a  quarter  inches,  all  died  as  a  consequence 
of  delivery  through  the  natural  passages. 

In  cases  where  the  uterus  is  rigidly  applied  to  the  child,  and  the  cervix  is 
undilated,  the  propriety  of  laparo-elytrotomy  is  questionable.  The  operation  is 
not  always  a  very  easy  one,  and  it  certainly  can  not  afford  to  be  handicapped 
by  anything  which  would  cause  delay  in  the  delivery  after  the  vaginal  rent  has 
been  made. 

There  are,  of  course,  in  so  rare  a  condition,  scant  statistics  in  favor  of  any 
special  plan  of  treatment.  Michaelis  reports  a  case  of  Mantz's,  that  of  a  woman 
who  had  a  pelvis  measuring  two  inches  antero-posteriorly,  and  three  inches  in 
the  transverse  diameter.  Here  the  Caesarean  section  became  a  matter  of  neces- 
sity rather  than  one  of  election.  Twice  the  operation  was  performed  with  suc- 
cess. A  third  time  the  result  promised  to  be  equally  favorable,  but  the  willful 
and  insubordinate  conduct  of  the  patient,  as  late  as  the  twenty-seventh  day,  led 
to  her  destruction. 

In  spite  of  the  fact  that  in  generally  contracted  pelves  craniotomy  is  nearly 
always  practicable,  and  notwithstanding  the  bad  repute  of  Ceesarean  section,  a 
careful  study  of  the  ground  convinces  me  that  where  there  is  a  diminution  of 
nearly  an  inch  in  all  the  diameters,  Caesarean  section,  or,  probably,  in  cases  of 
complete  dilatation  of  the  cervix,  laparo-elytrotomy,  holds  out  the  best  chances 
of  success. 

*  Naegele,  "  Das  schrag  verengte  Becken,"  p.  102. 
f  LoHLEixV,  op.  cit.^  p.  42. 

X  Spiegelberg,  "  Lehrbuch  der  Geburtshiilfe,"  p.  444,  vide  note. 

*  KoRMANN,  "  Ueber  ein  allgemein  verengtes,  schrag  verschobenes  Becken,"  "  Arch, 
f.  Gynaek.,"  p.  472. 


464 


THE  PATHOLOGY  OF  LABOR. 


2.  Cases  in  which  the  pelvic  contraction  is  such  as  to. prevent  the 
hirth  of  a  full-term  T,iving  child  through  the  natural  passages,  hut 
in  which  extraction  through  the  pelvis  furnishes  the  best  chance  of 
savifig  the  life  of  the  mother.  The  choice  of  measures  in  this  class  of 
cases  lies  between  craniotomy  and,  where  the  condition  of  things  is 
recognized  early  enough,  the  induction  of  premature  labor.  In  gen- 
eral terms  we  are  authorized  to  assume  such  a  degree  of  disproportion 
in  flattened  pelves  with  the  conjugate  ranging  between  two  and  a  half 
and  three  inches,  while  in  justo-minor  pelves  craniotomy  will  be 
usually  requisite  at  full  term,  even  with  a  conjugate  measuring  three 
and  a  third  inches.  In,  however,  these  less  extreme  degrees  of  de- 
formity, other  elements  than  those  of  the  size  of  the  pelvic  canal  enter 
into  the  formation  of  an  opinion  regarding  the  proper  procedure  to  be 
selected.  I  have  myself,  in  one  case,  extracted  a  child  weighing  six 
and  a  half  pounds  by  forceps,  without  much  difficulty,  through  a  gen- 
erally contracted  flattened  pelvis  with  a  conjugate  measuring  barely 
two  and  three  fourths  inches.  Labor  had  lasted  three  days  previous  to 
my  seeing  the  patient,  which  was  in  consultation.  The  child's  head 
presented  a  singular  appearance,  from  the  molding  it  had  undergone, 
having  been  greatly  flattened  in  its  biparietal  diameter  and  enor- 
mously elongated  in  the  occipito-mental  direction.  The  child  died, 
however,  shortly  after  birth.  The  mother  recovered,  though  consid- 
erable sloughing  of  the  vaginal  walls  followed  the  long  continuance  of 
the  pressure  which  had  preceded  delivery.  Grenser,  in  the  Dresden 
Hospital  Reports  (1861-1863),  gives  three  cases  of  children  born  alive 
where  the  pelvis  measured  two  and  three  quarters  inches.  In  one  of 
these,  where  the  labor  lasted  twenty-two  hours,  a  living  child  was 
born  weighing  six  and  a  half  pounds. 

If,  therefore,  labor  comes  on  at  full  term  before  craniotomy  is  pro- 
ceeded to,  an  attempt  should  be  made  to  gauge  the  degree  of  dispro- 
portion between  the  head  and  the  pelvic  brim,  for  not  only  is  it  among 
the  bare  possibilities  that  a  living  child  may  be  expelled  through  a 
pelvis  measuring  less  than  three  inches,  but  it  is  to  be  borne  in  mind 
that  in  pelvic  mensuration  even  the  most  expert  may  make  errors 
of  a  quarter  of  an  inch.  In  any  case  it  is  well  to  preserve  the  mem- 
branes as  long  as  possible.  Even  craniotomy  is  more  easily  performed 
after  complete  dilatation  of  the  os.  After  the  waters  escape,  the  lower 
uterine  segment  is  subjected  to  injurious  pressure  between  the  hard 
skull  and  the  pelvic  rim,  the  damage  done  increasing  of  course  with 
the  duration  of  labor.  By  early  perforation  and  evacuation  of  the 
brain-mass  this  danger  is  avoided.  But  craniotomy  should  not  be 
performed  so  long  as  the  hope  exists  of  saving  the  life  of  the  child. 
The  attempt  should  be  made,  at  least,  before  perforating,  to  form  an 
estimate  of  the  size  of  the  child's  head  and  its  relations  to  the  pelvic 
brim.    An  approximative  result  may  be  obtained  by  palpating  the 


TREATMENT  OF  CONTRACTED  PELVES. 


465 


head  throng-h  the  abdominal  walls  above  the  piibes,  and,  so  soon  as  the 
cervix  is  dilated  and  the  head  becomes  pressed  by  the  labor-pains  firmly 
against  the  brim,  by  introducing  the  half-hand  into  the  vagina  to  de- 
termine the  extent  of  that  portion  of  the  cranial  vault  which  has 
entered  the  pelvis.  When  we  have  ascertained  the  size  of  the  segment 
beneath  the  pelvic  border,  and  the  special  points  of  the  head  which 
occupy  the  several  pelvic  diameters,  we  are  in  a  position  to  estimate 
the  size  of  the  portion  above  the  brim,  and  the  mechanical  difficulties 
which  remain  before  the  engagement  of  the  head  can  be  accomplished. 

In  shoulder  presentations,  where,  of  course,  version  is  necessary, 
extraction  alone  should  be  first  tried,  and  only  when  it  is  found  impos- 
sible to  effect  the  delivery  of  the  after-coming  head  by  other  means 
should  perforation  be  resorted  to.  Schroeder  claims  to  have  extracted 
living  children  through  pelves  measuring  but  seven  and  a  half  centi- 
metres (three  inches)  in  the  conjugate.* 

The  induction  of  premature  labor  in  pelves  having  from  two  and 
three  quarters  to  three  inches  conjugate  diameter  possesses  the  merit 
of  diminished  risk  to  the  mother,  and  affords  a  chance  of  saving  the  life 
of  the  child.  Below  two  and  three  quarters  inches  the  advantages  of 
premature  labor  may  be  fairly  called  in  question.  To  be  sure,  Kiwisch 
placed  the  biparietal  diameter  of  the  child's  head  in  the  thirtieth 
week  at  two  and  a  half  inches.  Seyfert,  however,  fixed  it  at  three 
inches,  and  later  Schroeder  obtained  nearly  three  and  a  quarter  inches 
(8 '16  centimetres)  as  the  average  between  the  twenty-eighth  and  thirty- 
second  week.  In  point  of  fact  there  is  too  little  uniformity  in  the 
diameters  of  fetal  heads  belonging  presumably  to  the  same  week  of 
development  to  make  average  measurements  of  any  practical  utility. 
It  will  be  seen,  however,  that,  in  the  higher  degrees  of  pelvic  contrac- 
tion we  are  now  contemplating,  the  biparietal  diameter  of  the  child's 
head  rarely  falls  within  the  limits  of  the  narrowed  conjugate.  Still, 
it  is  possible  to  deliver  a  living  child  through  a  pelvis  estimated  at  two 
and  three  quarters  inches  as  late  as  the  thirty-fourth  week,t  as  the 
head,  owing  to  the  pliability  of  the  cranial  bones  in  premature  chil- 
dren, is  capable  of  sustaining  a  considerable  degree  of  lateral  compres- 
sion. K aturally  the  infant  mortality  in  these  cases  is  very  large.  In 
addition  to  the  ordinary  increased  risks  attendant  upon  premature 
labor,  intra-cranial  extravasations  of  blood  from  rupture  of  the  deli- 
cate cerebral  vessels  are  extremely  common.  Litzmann  found  in 
nearly  one  fourth  of  his  cases  (8  :  34)  spoon-shaped  depressions  of  the 
skull.  Though  this  lesion  is  often  met  with  upon  the  heads  of  living 
children  at  full  term,  in  the  series  of  Litzmann  four  of  the  children 
were  dead  at  birth,  three  showed  feeble  signs  of  vitality,  and  in  one 
only,  which  lived  but  fourteen  hours,  was  it  possible  to  excite  the 
*  Schroeder,  "  Lehrbuch  dcr  Gcburtshiilfe,"  p.  539. 

f  Wiener,  "  Zur  Fragc  der  kiinstlichen  Friihgeburt,"  "  Arch.  f.  Gynaek.,  Bd.  xiii,  p.  99. 
30 


466 


THE  PATHOLOGY  OF  LABOR. 


respiratory  process.  Thus  the  outlook  for  the  child  is  by  no  means 
hopeful ;  but,  inasmuch  as,  under  three  inches,  the  only  operations 
which  come  into  competition  with  premature  labor  are  the  Csesarean 
section  and  craniotomy,  a  small  saving  of  fetal  life  is  a  powerful  plea 
in  its  justification.  But  a  stronger  argument  in  its  favor  is  the  fact 
that  the  induction  of  premature  labor  offers  a  milder  procedure,  which, 
within  certain  limits,  inures  to  the  benefit  of  the  mother. 

Below  two  and  three  fourths  inches  the  chances  of  saving  the  child 
by  premature  labor  are  too  slight  to  be  weighed  in  the  balance.* 
Moreover,  unless  the  child's  head  happens  to  be  exceptionally  small 
and  yielding,  approximating  the  conditions  to  those  which  obtain  in 
immature  deliveries,  craniotomy  in  the  end  has  usually  to  be  resorted 
to.  Now,  as  premature  labor  offers  no  peculiar  advantages  in  the  per- 
formance of  craniotomy,  and,  as  it  is  attended  with  certain  risks  of 
its  own,  it  is  advisable,  in  very  narrow  pelves  after  the  twenty-eighth 
week,  to  await  the  normal  end  of  gestation. 

As  the  dangers  to  both  mother  and  child  are  increased  by  delay, 
Barnes  has  proposed  combining  version  with  premature  labor,  in 
pelves  of  less  than  three  inches  conjugate,  as  a  means  of  accelerating 
delivery.  Milne  {vide  note),  by  this  method,  extracted  a  living  child 
through  a  two  and  a  half  inch  pelvis.  Budin  has  found  by  experi- 
mentation with  artificial  pelves  that  a  much  less  amount  of  traction 
force  is  requisite  to  drag  the  head  of  a  premature  child  through  a  flat- 
tened conjugate  by  the  feet  than  by  forceps  in  cephalic  presentations. 

3.  Cases  in  tuliich  the  pelvic  contraction  does  not  exceed  the  limits 
within  ivhich  the  delivery  of  a  living  child  at  term  is  at  least  i^ossiUe. 
In  this  category  belong  the  overwhelming  majority  of  all  instances 
of  contracted  pelvis.  It  embraces  not  only  cases  in  which  the  con- 
junction of  every  favorable  condition  is  essential  to  delivery,  but  those 
moderate  degrees  of  narrowing  which  are  chiefly  recognizable  through 
the  influence  they  exert  upon  the  mechanism  of  labor.  It  includes 
flattened  pelves  with  a  conjugate  of  three  inches  and  upward,  and 
justo-minor  pelves  with  a  conjugate  of  over  three  and  a  tliird  inches. 
Below  these  figures  the  delivery  of  living  children  at  full  term  is  too 
exceptional  an  event  to  be  taken  into  account  in  any  attempt  at  classi- 
fication. 

The  obstetrical  resources  for  overcoming  the  mechanical  obstacles 
afforded  by  moderate  degrees  of  pelvic  contraction  are,  the  induction 
of  premature  labor,  craniotomy,  forceps,  and  version.    Each  one  of 

*  In  support  of  this  opinion,  which  is  thoroughly  confirmed  by  my  own  experience, 
wc  have  especially  the  authority  of  SriEGKLBERG,  Litzmann,  and  Dohrn.  Milne  ("  Prema- 
ture Labor  and  Version,"  "Edinburgh  Med.  Jour.,"  vol.  xix,  p.  VOV)  relates  a  case  where 
he  was  successful  in  a  pelvis  measuring  but  two  and  a  half  inches.  lie  states,  however, 
that  the  space  in  the  other  diameters  of  the  brim  was  ample,  which  was  certainly  an  ex- 
ceptional advantage,  as  nearly  all  pelves  with  the  higher  grades  of  deformity  belong  to 
the  category  of  generally  contracted  rachitic  pelves. 


TREATMENT  OF  CONTRACTED  PELVES. 


467 


these  measures  has  its  strenuous  partisans,  who  have  expended  much 
unprofitable  zeal  in  comparative  estimates  of  their  respective  values. 
It  is  a  mistake  to  regard  them  as  rival  pretenders  to  favor.  Indeed, 
the  very  conditions  which  indicate  one  form  of  procedure  often  ex- 
clude the  others  from  consideration.  Good  midwifery  requires  a  just 
appreciation  of  all  the  auxiliaries  at  our  disposition  and  a  careful  study 
of  the  circumstances  which  render  them  severally  appropriate. 

Premature  Labor. — The  indiscriminate  induction  of  premature 
labor  in  every  case  of  contracted  pelvis  is  particularly  to  be  deprecated. 
In  the  first  volume  of  the  "Archiv  fiir  Gynaekologie "  Spiegelberg 
presented  the  statistics  of  1,224  cases  of  full-term  labor  in  contracted 
pelvis,  in  which  the  maternal  mortality  was  6-6  per  cent,  and  the  in- 
fant mortality  28  per  cent. ;  while  in  271  cases  of  induced  premature 
labor  the  maternal  mortality  was  18*8  per  cent,  and  the  infant  mor- 
tality 66  per  cent.  This  startling  discrepancy  is  due  to  the  fact  that 
a  very  large  proportion  of  labors  in  contracted  pelves  either  terminate 
spontaneously,  or  require  forceps  only  after  uterine  action  has  over- 
come the  obstruction  at  the  brim.  If  all  these  minor  cases  be  omitted, 
a  very  different  result  is  obtained.  Thus,  Litzmann  found  that  in  flat- 
tened pelves  measuring  from  two  and  three  fourths  to  three  and  one 
fourth  inches  in  the  conjugate,  and  in  justo-minor  j)elves  between 
three  and  one  third  and  three  and  a  half  inches,  the  maternal  mortal- 
ity after  premature  labor  amounted  to  7*4  per  cent.,  while  the  loss  of 
life  in  labors  at  full  term  was  18*7  per  cent.*  But,  in  cases  of  recov- 
ery, the  advantages  of  premature  delivery  are  by  no  means  inconsider- 
able, as,  owing  to  the  diminished  head-pressure,  lesions  of  the  genital 
canal  are  of  rare  occurrence,  in  striking  contrast  to  the  fistulae,  lacera- 
tions, and  cicatrices  which  so  often  follow  delivery  at  full  term. 

The  prognosis  for  the  child,  as  shown  by  the  statistics  of  premature 
labor  in  contracted  pelves,  is  decidedly  unfavorable.  In  the  restricted 
class  of  cases  we  are  at  present  considering  Litzmann  found  that, 
though  twice  as  many  children  were  born  alive  as  at  full  term,  the 
actual  number  discharged  alive  from  the  hospital  was  about  the  same. 
He  concluded,  therefore,  that,  while  the  operation  was  decidedly  indi- 
cated in  the  interests  of  the  mother,  it  offered  a  dubious  advantage  to 
the  child.  It  is,  however,  always  injudicious  to  draw  deductions  from 
hospital  statistics  alone.  Especially  is  this  true  of  feeble  children, 
born  prematurely,  whose  ultimate  chances  depend  in  a  peculiar  degree 
upon  the  care  with  which  they  are  tended. 

Dohrn,  who  objected  to  the  statistics  of  Spiegelberg  and  Litzmann, 
on  the  ground  tliat  the  units  of  which  they  were  composed  repre- 
sented, not  parallel  cases,  but  an  endless  variety  of  dissimilar  condi- 
tions, proposed,  as  a  fairer  way  of  testing  the  value  of  induced  prema- 

*  Litzmann,  "  Ucbcr  den  Werth  dcv  kiinstlich  einglciteten  Friihgcburt  bei  Becken- 
enge,"  "Arch.  f.  Gynaek.,"  Bd.  ii,  p.  194. 


468 


THE  PATHOLOGY  OF  LABOR. 


ture  labor,  to  compare  the  results  of  the  latter  operation  with  those 
of  full-term  labors  in  the  same  patients.  Viewed  in  this  way,  prema- 
ture labor  in  contracted  pelves  has  been  found  to  furnish  unexpectedly 
favorable  results.  Thus,  Dohrn  reports  nineteen  cases,  with  forty-one 
children,  at  term,  of  which  thirty-seven  died.  In  twenty-five  preg- 
nancies premature  labor  was  induced,  with  fifteen  living  children.* 
Kunne  and  Berthold  report  eight  cases,  with  twenty-four  children  at 
term,  of  which  eighteen  died.  In  eighteen  pregnancies  premature 
labor  was  induced,  with  thirteen  living  children,  f  Still  more  extraor- 
dinary is  the  report  of  Milne.  Six  women  gave  birth  at  term  to  twelve 
children,  of  which  eleven  were  dead.  In  the  succeeding  thirty-eight 
pregnancies  premature  labor  was  induced,  and  thirty-five  children 
were  born  living.  J 

The  ordinary  time  for  bringing  on  labor  is  from  the  thirty-second 
to  the  thirty-fourth  week.  Most  writers  now  agree  that  the  operation 
should  be  restricted  to  pelves  measuring  less  than  three  and  a  half 
inches  in  the  conjugate,  whereas  above  that  limit  it  is  best  to  await 
the  results  of  spontaneous  uterine  action. 

Labor  at  End  of  Gestation. — But  the  physician  may  first  be  sum- 
moned to  a  case  of  contracted  pelvis  after  the  end  of  gestation  has 
been  reached,  or  he  may  at  an  earlier  period  have  decided  against  the 
induction  of  premature  labor. 

At  full  term,  supposing  the  head  to  present,  the  latter,  at  the^  be- 
ginning of  labor,  is  prevented  by  the  pelvic  narrowing  from  entering 
the  brim  of  the  pelvis,  and  is  usually  freely  movable.  The  conduct  of 
the  first  stage  of  labor  should  be  directed  to  preparing  the  way  for  the 
subsequent  delivery  of  the  child.  To  this  end  every  pains  should  be 
taken  to  prevent  rupture  of  the  membranes  until  the  cervical  dilata- 
tion has  become  complete.  The  patient  should  be  cautioned  against 
restless  movements  in  bed,  and  from  bearing  down  during  the  pains. 
Examinations  per  vaginam  should  be  made  with  great  care,  and  should 
be  avoided  except  where  absolutely  necessary.  The  largest-sized  Barnes 
dilator,  moderately  distended  with  fluid,  placed  in  the  vagina  to  exert 
counter-pressure  upon  the  cervix,  is  at  times  of  use  where  the  mem- 
branes have  a  tendency  to  protrude  in  the  form  of  a  narrow  cylinder. 

Attention  should  likewise  be  directed  to  faulty  positions  and  pres- 
entations of  the  child's  head.  Should  these  be  dependent  upon  a 
pendulous  abdomen,  the  fundus  of  the  uterus  should  be  elevated,  and 
the  normal  relations  of  the  uterine  axis  maintained  by  a  suitably  ad- 
justed bandage.    Excessive  lateral  obliquity  should  be  corrected  by 

*  Dohrn,  "  Ueber  kiinstliche  Friihgcburt  bei  cngcn  Ecckcn,"  "  Arch.  f.  Gynack.," 
Bd.  xii,  p.  70. 

f  KuNNK,  Funfzehn  Falle  der  kiinstlichcn  Friiligcburt "  ;  Berthold,  "  Zur  Statistik 
dcr  kunstlichen  Fruhgeburt,"  "Arch.  f.  Gynaek.,"  Bd.  vi.  Heft  2. 

X  Milne,  "  Premature  Labor  and  Vci-sion,"  "  Edinburgh  Med.  Jour.,"  vol.  xix. 


TREATMENT  OF  CONTRACTED  FELYES. 


469 


placing  the  patient  upon  the  opposite  side.  Should  transverse  nar- 
rowing require  a  deep  descent  of  the  occiput,  this  can  be  furthered  by 
placing  the  woman  upon  the  side  to  which  the  occiput  is  directed. 
Where,  on  the  other  hand,  it  is  desirable  to  promote  the  dip  of  the 
forehead,  the  patient  should  be  made  to  lie  upon  the  side  to  which  the 
child's  face  is  turned.  The  reason  of  this  is  obvious,  as,  when  the 
breech  falls  to  a  given  side,  the  cephalic  pole  has  a  tendency  to  move 
in  the  opposite  direction.  The  right  use  of  position  as  a  corrective 
force  depends  upon  the  degree  of  accuracy  with  which  the  character 
of  the  pelvic  deformity  is  estimated,  and  upon  a  proper  appreciation 
of  the  mechanism  appropriate  to  the  ascertained  deformity. 

Where  the  sagittal  suture  looks  forward  toward  the  symphysis 
pubis,  so  that  the  posterior  parietal  bone  becomes  the  presenting  part, 
a  firm  compress  above  the  pubes  may  be  advantageously  employed  to 
press  the  head  backward  and  approximate  the  sagittal  suture  to  the 
median  line. 

The  pains,  when  weak  and  inefficient,  should  be  strengthened  by 
the  warm  vaginal  douche  ;  when  the  source  of  exaggerated  suffering, 
they  should  be  mitigated  by  morphia,  by  rectal  injections  of  chloral, 
or  by  the  administration  of  an  anaesthetic. 

Should,  by  good  fortune,  the  rupture  of  the  membranes  be  post- 
poned until  after  the  completion  of  cervical  dilatation,  one  of  two 
contingencies  may  follow  :  1.  The  disproportion  between  the  head  and 
the  pelvis  may  prove  to  be  slight,  so  that  a  considerable  segment  of  the 
cranial  vault  may  be  felt  below  the  brim  ;  then,  provided  the  head  en- 
ters the  pelvis  in  conformity  with  the  mechanical  laws  dictated  by  the 
character  of  the  pelvic  deformity,  the  expulsion  of  the  child  may  be  left 
to  the  natural  uterine  forces.  2.  No  engagement  may  take  place,  the 
head  continuing  freely  movable,  at  the  brim.  Under  such  circum- 
stances the  disproportion  may  be  assumed  to  be  considerable.  The 
physician  has,  therefore,  to  ask  himself  whether  he  shall  await  the 
action  of  the  pains,  in  the  expectation  that  the  head  will  gradually 
adapt  itself  to  the  pelvis,  or  whether  he  shall  at  once  proceed  to  per- 
form version,  and  drag  the  child  rapidly  through  the  straitened  diam- 
eters. The  forceps,  as  a  means  of  delivery  before  fixation  of  the  head, 
should  be  discarded,  not  because  it  can  not  be  employed  with  success, 
but  because  its  use,  even  in  the  most  skillful  hands,  is  extra-haz- 
ardous. 

The  question  of  waiting,  or  proceedin;^  at  once  to  version,  is  one 
that  will  always  be  decided  largely  by  the  individual  experiences  of  the 
accoucheur.  It  is,  however,  vain  to  deduce  rules  of  practice  from  the 
conduct  of  those  who  have  enjoyed  exceptional  opportunities,  and  who 
usually  have  developed  exceptional  skill  in  some  one  special  direc- 
tion. It  is  to  be  remembered  that  in  contracted  pelves,  in  case  the 
pains  prove  inadequate  to  overcome  the  obstacles  to  delivery,  the  alter- 


470 


THE  PATHOLOGY  OF  LABOR. 


natives  in  head  presentations  are  forceps  and  perforation.  But  there 
are  very  few  experienced  operators  who  have  not  a  more  or  less  per- 
sonal predilection  for  either  forceps  or  version,  and  this  unconscious 
bias  exercises,  necessarily,  to  some  extent,  a  determining  influence  upon 
their  choice.  It  is  well  known  that  there  is  hardly  any  subject  which 
has  been  the  source  of  so  much  heated  controversy  as  the  one  at  pres- 
ent under  discussion.  For  the  profession  at  large,  however,  there  is 
little  to  be  gained  from  the  spirit  of  partisanship.  The  general  prac- 
titioner requires  instruction  not  only  in  the  special  advantages  pos- 
sessed by  each  measure,  but  needs  to  have  presented  to  his  attention 
parallel  statements  of  the  dangers  and  difficulties  from  which  neither 
procedure  is  free. 

Version. — In  considering  the  application  of  version  to  the  treat- 
ment of  contracted  pelves,  it  is  well  to  state  in  advance  certain  points 
which  are  rarely  alluded  to,  probably  because  they  are  matters  of  tacit 
agreement  betAveen  the  contending  parties  to  whose  disputes  we  main- 
ly owe  our  present  knowledge  in  relation  to  the  subject. 

The  first  of  these  points  is,  that  the  intent  of  the  operation  is  to 
save  the  life  of  the  child.  In  the  case,  therefore,  of  a  dead  child,  or 
of  one  in  which  the  heart-sounds  have  notably  begun  to  fail,  version 
affords  no  advantage  over  perforation.  For  the  same  reason  the  condi- 
tions must  be  such  as  to  hold  out  a  reasonable  hope  of  rapid  delivery 
of  the  child's  head,  without  the  infliction  of  necessarily  fatal  lesions. 
Now,  there  does  not  appear  to  be  any  well-authenticated  case  of  the 
extraction  of  a  full-term  living  child  after  version  through  a  flattened 
pelvis  measuring  less  than  two  and  three  quarters  inches  in  the  conju- 
gate diameter.  But  even  with  three,  or  three  and  a  quarter  inches,  the 
result  will  still  depend  upon  the  length  of  the  transverse  diameter. 
Thus,  in  extreme  degrees  of  the  justo-minor  pelvis,  with  the  reduction 
of  nearly  an  inch  in  all  the  diameters,  the  difficulties  of  delivering  the 
after-coming  head,  even  with  the  aid  of  the  perforator  and  the  cephalo- 
tribe,  are  wellnigli  insurmountable.  Again,  the  contraction  should  be 
limited  to  the  pelvic  brim,  for,  where  it  is  continuous,  or  progressively 
increases  toward  the  outlet,  the  fate  of  the  child  is  not  even  doubt- 
ful. 

The  other  point  of  importance  is,  that  with  three  and  a  half  inches 
and  upward  in  the  conjugate,  no  interference  is,  as  a  rule,  called  for. 
Since  it  has  become  the  custom  to  measure  pelves  with  accuracy,  the 
profession  has  learned  that  these  moderate  degrees  of  deformity  exer- 
cise their  influence  not  so  much  in  a  mechanical  way  as  in  the  modi- 
fying effects  they  produce  upon  labor.  A  large  proportion  of  the  cases 
terminate  spontaneously.  If  the  pains  fail  prematurely,  the  conditions 
are  generally  such  as  to  make  it  an  easy  matter  to  deliver  with  forceps. 
Difficulties  only  arise  where  the  head  is  unusually  large  and  incom- 
pressible, or  in  faulty  positions,  such  as  the  anterior  dip  of  the  head  in 


TREATMENT  OF  CONTRACTED  PELVES. 


471 


justo-minor  pelves,  and  the  presentation  of  the  posterior  parietal  bone 
in  the  flattened  varieties. 

Thus,  version  is  indicated  in  contracted  pelves  only  where  the 
child's  heart  beats  with  nearly  unimpaired  vigor,  and  in  pelves  meas- 
uring between  two  and  three  quarters  and  three  and  a  half  inches 
antero-posteriorly,  with  the  contraction  limited  to  the  brim,  and  with 
sufficient  amplitude  in  the  transverse  diameter. 

The  advantages  of  version  in  contracted  pelves  grow  out  of  the 
unquestioned  fact  that  the  after-coming  head  passes  more  readily  the 
contracted  brim  than  the  normal  head-first  presentation.  This  supe- 
rior facility  is  attributable  to  the  entry  of  the  head  by  its  smaller 
bimastoid  diameter.  At  the  same  time,  the  fronto-occipital  descends 
in  the  transverse  diameter  of  the  pelvis. 
The  pressure  of  the  conjugate  is  encoun- 
tered by  the  bitemporal  diameter  of  the 
child's  head,  which  measures  a  half-inch  less 
than  the  biparietal.     Tractions  upon  the 


trunk  of  the  child  bring  to  bear  simulta- 
neously pressure  upon  the  head  from  many 
points  in  the  pelvic  walls.  As  a  result,  bi- 
lateral flattening  is  eft'ected,  and  a  deep 
groove,  usually  near  the  coronal  suture,  is 
produced  in  many  cases  upon  the  posterior 
cranial  surface  by  the  pressure  of  the  pro- 
jecting promontory.  The  bulk  of  the  head 
is  still  further  diminished  by  an  overriding 
of  the  bones  at  the  sagittal  suture,  and, 
where  the  transverse  diameter  is  insufficient, 

by  the  crowding  of  the  occipital  beneath  the  parietal  bones.  A  reduc- 
tion of  the  cranial  contents  is  brought  about  by  the  retreat  of  a  con- 
siderable portion  of  the  cercbro-spinal  fluid  into  the  spinal  canal.  All 
these  changes  are  induced  rapidly,  and  are  not  dependent  upon  the 
activity  and  strength  of  the  uterine  pains. 

The  method  of  performing  version  and  extraction  in  contracted 
pelves  is,  with  few  modifications,  the  same  as  in  pelves  of  normal  size. 
In  contracted  pelves  great  care  requires  to  be  taken  lest  the  arms  be- 
come reflected  upward  to  the  sides  of  the  child's  head,  or  crossed  upon 
the  neck.  To  avoid  this  difficulty  it  is  desirable  to  introduce  the 
hand  over  the  abdomen  of  the  child,  and  bring  down  the  arms  before 
the  engagement  of  the  shoulders.  In  extracting  the  head,  tractions 
may  be  made  upon  the  lower  extremities  and  shoulders  according  to 
the  method  of  Kiwisch,  or  they  may  be  made  with  one  hand  upon 
the  shoulders,  while  two  fingers  of  the  other  are  inserted  into  the 
child's  mouth.  Provided  by  either  of  these  methods  the  relation  of 
the  head  to  the  shoulders  is  such  that  no  twistins:  of  the  neck  takes 


Fig.  207.— Base  ot  skull :  M  M, 
bimastoid  diameter. 


472 


THE  PATHOLOaY  OF  LABOR. 


place,  the  amount  of  force  that  can  be  employed  without  producing 
fatal  lesions  is  often  something  astounding.  Thus,  Rokitansky,*  ex- 
perimenting with  the  bodies  of  still-born  infants,  found  the  utmost 
strength  put  forth  by  two  men  upon  the  trunk  was  insufficient  to 
cause  rupture  of  the  vertebral  ligaments  and  separation  of  the  artic- 
ulations. It  is  usual,  however,  to  combine  pressure  from  above, 
exercised  by  a  skilled  assistant  upon  the  head  through  the  abdomi- 
nal walls,  with  tractions  from  below.  Schroeder  states  f  that  this 
practice  is  coeval  with  podalic  version.    It  was  known  to  Celsus  and 


Fig.  208. — Method  of  employing  supra-pubic  pressure.    Head  in  the  pelvic  cavity. 


recommended  by  Ambroise  Pare.  It  has  found  warm  advocates  in 
Pugh,  Wigand,  Martin,  Kristeller,  and  in  this  country  in  Taylor  and 
Goodell.  Both  the  latter  gentlemen  have  made  valuable  suggestions 
regarding  the  technical  management  of  difficult  cases,  which  are  well 
worthy  of  special  mention.  Dr.  Taylor  |  at  first  draws  the  body  di- 
rectly backward,  while  the  head  is  forced  by  supra-pubic  pressure 
downward  and  backward  into  the  pelvis.  So  soon,  however,  as  the 
head  begins  to  advance,  he  raises  the  body  of  the  child  and  directs 
pressure  upon  the  head  to  be  made  downward  and  forward  in  the  axis 
of  the  outlet.  In  case  of  failure  or  delay,  he  has  sometimes  succeeded 
by  intentionally  directing  the  back  of  the  child  to  the  sacrum,  and 
then  causing  the  occiput  to  be  pressed  downward  and  back)vard  into 

*  RoKiTANSKY,  "  Wicn.  mcd.  Presse,"  18*74,  No.  45. 
f  Schroeder,  "  Ilandbuch,"  6te  Aufl.,  p.  307. 

I  Taylor,  "  What  is  the  Best  Treatment  in  Contracted  Pelves  ?  "  p.  23. 


\ 


TREATMEXT  OF  CONTRACTED  PELVES. 


473 


the  nearest  sacro-iliac  space,  with  the  face  looking  upward,  while  trac- 
tion is  made  in  the  axis  of  the  outlet.  Dr.  Goodell,*  after  first  draw- 
ing in  the  direction  of  the  outlet,  with  the  assistant  pushing  down- 
ward and  backward,  reverses  the  direction,  and  sweeps  the  child's 
body  backward  upon  the  coccyx,  the  neck  likewise  being  forced 
downward  and  backward  into  the  hollow  of  the  sacrum  with  all 
one's  power.  Where  the  projection  of  the  promontory  is  not  very 
marked,  he  likewise  recommends  as  sometimes  of  assistance  a  pumj)- 
handle  movement,  the  range  of  oscillation  extending  from  the  axis 
of  the  outlet  anteriorly  to  very  firm  pressure  on  the  coccyx  j^oste- 
riorly. 

It  is  obvious  from  the  foregoing  description  that  version  and  ex- 
traction in  contracted  pelves  expose  the  child  to  perils  of  no  insignifi- 
cant character.  Among  the  lesions  which  have  been  observed  as  a 
result  of  the  extreme  traction  force  necessary  to  bring  the  head  rapidly 
through  the  narrow  brim  are  fracture  of  the  clavicles,  fracture  of  the 
humerus  in  difficult  arm-deliveries,  lacerations  of  the  sterno-cleido- 
mastoid  muscles,  rupture  through  the  substance  of  a  vertebra,  extrav- 
asations of  blood  into  the  cavities  of  the  head  and  trunk,  separation 
of  the  condyles  from  the  occij^ut,  and  of  the  squamous  portion  of  the 
temporal  from  the  parietal  bones,  fractures  and  depressions  of  the 
skull,  and  rupture  of  the  sinuses  of  the  dura  mater,  f  To  be  sure, 
many  of  these  accidents  are  not  inevitably  fatal,  but  they  do  not  by 
any  means  furnish  the  chief  sources  of  danger.  These  result  partly 
from  the  respiratory  efforts  which  are  always  excited  by  delay  in  ex- 
tracting the  after-coming  head,  and  partly  from  the  depressing  influ- 
ence exercised  upon  the  fetal  heart  by  pressure  brought  to  bear  ui^on 
the  base  of  the  brain.  I 

Having  thus  made  out,  with  great  care,  a  full  bill  of  particulars, 
embracing  all  the  acknowledged  drawbacks  to  the  performance  of  ver- 
sion in  narrow  pelves,  we  have  next  to  consider  how  far  these  associ- 
ated evils  tend  to  invalidate  the  claim  of  version  to  be  regarded  as 
facile  princeps  among  conservative  measures  of  treatment.  The  fol- 
lowing records  of  the  individual  experience  of  competent  operators 
will  help  us  to  solve  this  question.  Kormann  turned  in  nine  cases  of 
contracted  pelves.  Seven  children  were  born  living,  and  two  dead. 
All  the  mothers  recovered.*  Lowenhardt  turned  in  twenty  cases  of 
contracted  pelves.  Seventeen  children  were  born  alive,  and  three 
dead.    Only  children  that  outlived  the  first  week  were  counted  in  the 

*  GooDELL,  "  Clinical  Memoirs  on  Turning  in  Contracted  Pelves,"  "  Am.  Jour,  of 
Obstet.,"  vol.  viii,  p.  211. 

f  C.  RuGE,  "  Vcrletzungen  des  Kindes  durcli  Extraction  bei  Beckenlage,"  "  Ztsehr.  f. 
Geburtsh.,"  Bd.  i,  p.  68. 

X  DoHRN,  '*  Ucbcr  Pulslosigkeit  des  Kindes  wahrend  Extraction  an  den  Fiissen," 
"Arch.  f.  Gynack.,"  Bd.  vi,  p.  365. 

*  KoKMAKN,  "Arch.  f.  Gynaek.,"  Bd.  vii,  p.  13. 


474 


THE  PATHOLOGY  OF  LABOR. 


successful  cases.  The  mothers  recovered.*  Goodell  reports  eleven 
cases.  Four  children  were  alive  at  birth,  and  four  were  still ;  but,  of 
the  latter,  one  was  extracted  through  a  pelvis  measuring  only  two  and 
a  half  inches  conjugate  diameter,  and  in  one  the  case  was  complicated 
by  eclampsia.  The  mothers  recovered.  Now,  not  to  go  beyond  these 
forty  cases,  we  obtain,  as  the  result  of  version,  thirty-one  living  in- 
fants, without  the  sacrifice  of  a  single  mother.  A  number  of  the 
women  in  whose  previous  labors  craniotomy  had  been  found  neces- 
sary were  delivered  by  version  of  living  children.  Lowenhardt  placed 
in  contrast  his  own  experience  with  the  forceps  in  narrowed  pelves 
presenting  degrees  of  contraction  corresponding  to  those  in  which  he 
had  resorted  to  version.  In  forty-five  deliveries,  sixteen  children  were 
born  dead  and  five  died  shortly  after  birth.  Of  the  mothers,  three 
died,  while  twenty-one  sulfered  from  puerperal  aifections  of  greater  or 
less  severity. 

Now,  if  the  foregoing  testimony  represented  the  entire  truth,  there 
would  be  no  good  reason  for  discussing  other  plans  of  treatment. 
They,  in  fact,  show  only  how  far  special  training  and  experience  will 
enable  an  operator  to  overcome  difficulties  by  dexterity  and  address. 
In  the  first  case  reported  by  Dr.  Goodell  the  child  was  still-born.  In 
commenting  upon  the  cause  of  death  Dr.  Goodell  states  frankly  : 
*^  Much  force  was  needed  to  extract  the  head,  but  it  was  not  made  as 
promptly  and  efficiently  as  I  have  since  learned  to  make  it."f 

Another  side  of  the  question  has  been  presented  by  Borinski,J;  who, 
at  the  instigation  of  Professor  Spiegelberg,  collected  the  statistics  of 
version  in  contracted  pelves  from  the  Breslau  Clinic  between  the  years 
1865-1872.  In  all  there  were  ninety-three  cases.  Thirty- four  chil- 
dren were  saved,  and  fifty-nine  were  born  dead,  or  died  soon  after 
birth.  Fifteen  mothers  lost  their  lives.  This  seemingly  disastrous 
showing  is  capable,  however,  to  a  certain  degree,  of  explanation.  Thus, 
twenty  of  the  fifty-nine  children  born  still  died  before  version  was 
attempted.  In  nine  of  the  cases  the  transverse  as  well  as  the  conju- 
gate was  materially  diminished.  Of  the  children  delivered  through 
these  flattened  generally  contracted  pelves,  only  one,  and  that  a  very 
small  one,  was  extracted  alive.  Still,  there  were  fifty-eight  cases  of 
version  in  ordinary  flattened  pelves,  with  the  result  that  just  one  half 
the  children  were  born  dead.  In  only  three  of  the  fifteen  mothers 
who  died  was  the  fatal  result  apparently  connected  with  the  opera- 
tion. In  the  others,  death  was  due  to  spontaneous  rupture  of  the 
uterus,  placenta  praevia,  and  nephritis,  version  having  been  resorted 

*  LciwENiiARDT,  "  Wendung  und  Extraction  das  dominircnde  Vcrfaliren  bei  Bcckcn- 
enge,"  "Arch.  f.  Gynaek  ,"  Bd.  vii,  p.  421. 

f  Goodell,  "Trans,  of  the  Intcrnat.  :Med.  Congr.,"  Bhiladelphia,  1876,  p.  111. 

Ij.  BoRiNSKi,  "  Zur  Lchrc  von  der  Wendung  auf  die  Fiissc  bei  cngen  Bccken,"  "  Arch, 
f.  Gynaek.,"  Bd.  Iv,  p.  22G. 


TREATMENT  OF  CONTRACTED  PELVES. 


475 


to  because  of  these  complications.  A  considerable  allowance  should 
be  made,  too,  in  the  cases  from  the  Breslau  Clinic,  for  the  fact  that 
the  greater  part  of  them  took  place  in  the  out-department  of  the  hos- 
pital, when  they  were  under  the  charge  of  midwives,  who  rarely  send 
for  timely  aid  except  in  the  presence  of  dangerous  complications.  In 
eighteen  instances  the  operation  was  performed  on  account  of  pro- 
lapse of  the  cord,  and  in  eighteen  instances  because  of  some  maternal 
affection. 

Forceps. — In  presenting  this  less  favorable  side  of  version  in  con- 
tracted pelves,  it  is  well  incidentally  to  place  in  juxtaposition  the  re- 
sults of  the  high  forceps  operation  as  given  by  Dr.  Harold  Williams, 
in  a  recent  number  of  the  '^American  Journal  of  Obstetrics"  (Jan- 
uary, 1879).  Williams  collected  one  hundred  and  nineteen  cases,  re- 
ported since  1858,  where  the  forceps  was  applied  to  the  head  above  the 
brim.  Of  the  mothers  nearly  forty  per  cent.,  and  of  the  children  over 
sixty  per  cent.,  perished.  The  mechanical  objections  to  the  use  of 
forceps  at  the  brim  are  obvious.  When  the  head  is  molded  to  the 
contracted  pelvis  by  the  natural  forces,  the  head  passes  the  conjugate 
with  its  long  diameter  in  the  transverse  diameter  of  the  pelvis,  with 
the  two  fontanelles  on  nearly  the  same  level,  and  with  the  sagittal 
suture  looking  toward  the  sacrum.  The  posterior  parietal  bone  ro- 
tates around  the  promontory,  the  latter  producing  a  furrow  which 
runs  either  along  the  coronal  suture,  or  at  first  in  front  of  the  parietal 
boss,  and  later,  as  flexion  occurs,  forward  toward  the  frontal  bone. 
The  bilateral  compression  of  the  head  is  compensated  for  in  part  by 
a  lengthening  in  the  fronto-occipital  and  partly  in  a  vertical  direc- 
tion. 

The  forceps  applied  in  the  transverse  or  oblique  diameter  of  the 
pelvis  prevents  the  former  compensation  from  taking  place.  It  in- 
creases the  width  of  the  head,  and  thus  adds  to  the  difficulty  of  pass- 
ing the  conjugate.  Often  it  disturbs  further  the  normal  head  mechan- 
ism by  causing  premature  flexion  and  rotation  to  take  place.  In  each  of 
these  ways  it  augments  the  difficulties  of  delivery,  and  renders  neces- 
sary the  employment  of  an  increased  amount  of  traction  force.  With 
forceps  applied  directly  to  the  sides  of  the  child's  head  I  have  had  no 
experience,  but  Dr.  Goodell,*  who  has  clearly  pointed  out  the  objec- 
tions to  this  method  in  contracted  pelves,  has  shown  that  they  inevi- 
tably produce  flexion,  and  cause  the  large  biparietal  diameter  to  pass 
through  the  narrow  conjugate.  So  long  as  the  head  does  not  engage 
at  the  brim,  there  is  no  rivalry  between  version  and  forceps.  The 
latter  should  be  placed  under  the  ban  as  hardly  less  dangerous  than 
the  Caesarean  section. 

Expectant  Treatment. — Now,  let  us  suppose  that  after  rupture  of 

*  Goodell,  "Labor  in  Narrow  Pelves,"  "Trans,  of  the  Internat.  Med.  Congr.,"  Phila- 
delphia, 1876,  p.  788. 


476 


THE  PATHOLOGY  OF  LABOR. 


the  membranes  it  is  decided  to  resort  to  neither  forceps  nor  version, 
but  to  adopt  an  expectant  course,  until  circumstances  arise  which  shall 
render  active  interference  necessary.  It  is  certain  that  a  very  consid- 
erable portion  of  labors  in  contracted  pelves  terminate  spontaneously. 
Winckel*  reports  twenty-three  cases  in  the  Dresden  Maternity  in  1873, 
and  twelve  cases  in  1874-'75.  Of  the  thirty-five  cases,  two  mothers 
and  three  children  died.  Osterloh  f  reported  one  hundred  and  thirty- 
nine  cases  from  the  Leipsic  Maternity,  between  the  years  1863-1872 
inclusive.  There  were  one  hundred  and  five  cases  where  the  pelves 
measured  from  three  to  three  and  a  half  inches.  Of  one  hundred  and 
six  children,  seven  died.  Of  the  mothers  four  died.  In  thirty-four 
cases  where  the  pelves  measured  over  three  and  a  half  inches,  two  chil- 
dren died.  All  the  mothers  recovered.  There  were,  however,  forty- 
two  cases  in  all  of  puerperal  disease  terminating  in  recovery.  Borinski 
reports  from  the  Breslau  Clinic  two  hundred  and  thirty -three  spon- 
taneous deliveries  in  contracted  pelves,  with  one  hundred  and  ninety- 
two  living  children.  There  were  ten  maternal  deaths,  but  four  were 
from  non-puerperal  intercurrent  affections.  Thus,  in  three  large  ma- 
ternity hosjiitals  there  were  in  cases  of  contracted  pelves  four  hundred 
and  seven  spontaneous  deliveries,  with  the  loss  of  fifty-three  children, 
and,  from  puerperal  diseases,  of  twelve  mothers,  the  latter  represent- 
ing very  nearly  the  usual  mortality  in  lying-in  hospitals.  Even  in 
pelves  measuring  less  than  three  inches,  now  and  then,  the  spontaneous 
birth  of  a  small  living  child  takes  place. 

If  we  examine  these  results,  we  find  that  under  favorable  circum- 
stances, in  all  but  the  extreme  forms  of  pelvic  contraction,  Nature  will 
do  her  own  work  with  the  least  expense  of  infant  life,  and  with  a  rela- 
tively small  maternal  mortality.  On  the  other  hand,  the  long-contin- 
ued pressure  upon  the  parturient  canal,  incident  to  the  molding  and 
adaptation  of  the  head  to  the  narrow  pelvis,  yields  a  large  contingent 
of  inflammatory  affections,  which  complicate  the  puerperal  period  and 
protract  the  convalescence.  By  favorable  circumstances  we  mean  a 
presentation  and  position  of  the  child's  head  suited  to  the  form  of  the 
pelvis,  and  a  sufficient  degree  of  uterine  activity.  Rectification  of  a 
faulty  position  of  the  head  after  the  rupture  of  the  membranes  is 
always  a  matter  difficult  of  accomplishment.  In  case,  therefore,  the 
brow  presents,  or  the  head  engages  with  an  excessive  degree  of  lateral 
obliquity  (sagittal  suture  looking  forward  toward  the  pubes,  or  back- 
ward toward  the  promontory),  in  place  of  wasting  time  in  futile  efforts 
at  correcting  the  malposition,  version  should  be  promptly  performed. 
In  prolapse  of  the  cord,  which  occurs  in  about  six  per  cent,  of  the 
cases,  the  indication  would  clearly  be  version  rather  than  replacement. 

*  WiNCKEL,  "Bcrichte  und  Studien,"  18'74-'76. 

•{■  Osterloh,  "  Einigc  Beitrage  zu  den  spontan  verlaufenden  Geburtcn  bei  cngem 
Bcckcn,"  "  Arch,  f .  Gynack.,"  Bd.  iv,  p.  520. 


TREATMENT  OF  CONTRACTED  PELVES. 


477 


In  eclampsia  and  face  presentations  most  operators  would  preferably 
resort  to  version. 

Thus,  we  have  finally  the  field  of  controversy  between  version  and 
other  plans  of  treatment  narrowed  down  to  cases  in  which,  after  rupt- 
ure of  the  membranes,  the  head  remains  above  the  brim,  but  the  con- 
ditions are  such  that  Nature  is  capable  of  overcoming  the  mechanical 
difficulties  of  delivery  providing  that  the  labor-pains  are  sufficiently 
energetic.  There  is  always  an  element  of  chance  in  this  last  condition, 
which,  however,  is  an  essential  one.  If  the  pains  are  weak  and  pow- 
erless, it  may  be  possible,  even  hours  after  rupture  of  the  membranes, 
when  the  head  has  not  become  fixed,  to  still  accomplish  version.  More 
frequently,  however,  as  the  head  but  incompletely  fills  the  lower  seg- 
ment of  the  uterus,  the  waters  escape,  the  uterus  retracts  upon  the 
foetus,  the  cervix  becomes  oedematous  and  tender,  and  after  a  time 
the  temperature  and  pulse  rise,  betokening  the  presence  of  danger. 
Sometimes  the  retraction  of  the  uterus  ends  in  the  withdrawal  of  the 
cervix  over  the  child's  head,  and,  in  the  failure  of  the  latter  to  de- 
scend into  the  pelvis,  the  vagina  is  drawn  upward,  and  subjected  to  a 
perilous  degree  of  tension.  It  is  easy  to  see  that  under  such  cir- 
cumstances the  time  for  version  is  past,  and  craniotomy  is  called  for. 
Because,  therefore,  where  labor  is  left  in  contracted  pelves  to  the  spon- 
taneous efforts  of  Nature,  in  a  certain  proportion  of  cases  the  insuf- 
ficiency of  the  labor-pains  leads  to  the  necessity  of  cacrificing  the  child, 
there  will  ahvays  be  operators  who,  confident  in  their  own  skill,  will 
prefer  to  turn  soon  after  rupture  of  the  membranes,  that  they  may 
keep  in  their  hands  the  control  of  the  delivery.  The  bulk  of  pro- 
fessional men  will,  on  the  contrary,  so  long  as  spontaneous  delivery 
is  probable,  prefer  to  wait,  even  though  by  so  doing  they  may  eventu- 
ally find  themselves  obliged  to  fall  back  upon  the  perforator  and  the 
crotchet. 

AYhen  the  birth  of  the  child  is  left  to  the  contractions  of  the 
uterus,  reenforced  by  tlie  expiratory  muscles,  the  physician  should 
assume  the  role  of  a  watchful  spectator.  Safety  to  the  mother  and 
the  child  requires  that  the  time  of  the  passage  of  the  head  through  the 
bony  canal  should  not  be  too  prolonged.  So  long  as  the  head  de- 
scends steadily,  however  slow  the  progress  may  be,  in  case  no  compli- 
cations demand  speedy  extraction,  the  physician  should  await  the 
results  of  uterine  activity.  Should  the  pains  grow  weak  and  inef- 
ficient, they  may  be  stimulated  by  the  uterine  douche,  the  introduction 
of  the  catheter  into  the  uterus,  and  by  small  doses  of  ergot  or  the 
viscum  album,  provided  the  inertia  is  not  the  result  of  pathological 
changes  in  the  uterine  tissues. 

When  tlie  advance  of  the  head  ceases,  either  from  failure  of  the 
pains  or,  as  in  justo-minor  pelves,  from  the  growing  resistance  of  the 
pelvic  outlet,  the  rule  should  be  to  relieve  the  soft  parts  of  the  mother 


478 


THE  PATHOLOGY  OF  LABOR. 


as  speedily  as  possible  from  the  pressure  of  the  child's  head.  Press- 
ure too  long  continued  ends  in  cedematous  swelliag,  softening  of  the 
tissues,  arrest  of  circulation,  and  eventually  in  necrosis  and  gangrene. 
When  the  integrity  of  the  lower  segment  of  the  uterus  has  been  im- 
paired to  any  extent,  perforation  should  be  resorted  to,  and  the  child 
sacrificed  to  the  interests  of  the  mother.  If,  on  the  contrary,  the 
changes  are  insignificant,  and  the  mechanical  difficulties  not  insuper- 
able, by  the  use  of  forceps  it  may  be  possible  to  save  the  life  of  both 
mother  and  child.  But  to  avoid  the  first-named  cruel  alternative,  the 
forceps  should  be  applied  so  soon  as  the  requisite  conditions  for  its 
employment  arc  reached.  Of  course,  as  the  forceps  is  used  solely  to 
save  fetal  life,  in  case  the  feeble  heart-action  of  the  child  gives  warn- 
ing of  impending  asphyxia  the  interests  of  the  mother  are  to  be  alone 
consulted. 

In  estimating  the  mechanical  difficulties  to  be  overcome  by  the 
forceps,  it  is  necessary  to  determine  how  far  engagement  has  taken 
place.  Litzmann  *  recommends  that  the  physician  ascertain  by  inter- 
nal examination,  combined  with  external  palpation,  both  the  size  of 
the  segment  of  the  cranium  below  the  brim  and  how  much  of  the 
head  remains  to  undergo  compression  before  it  can  enter  the  pelvis. 

In  ordinary  flattened  pelves,  Litzmann  found  that  in  three  fourths 
of  all  the  cases  the  pains  alone  sufficed  to  overcome  the  resistance  of 
the  brim.  When  the  head  had  so  far  descended  that  the  sagittal  suture 
had  passed  from  three  to  four  fifths  of  an  inch  below  the  promontory, 
and  the  boss  of  the  anterior  parietal  bone  could  be  felt  with  ease 
behind  the  symphysis  pubis,  extraction  with  the  forceps  was  a  task  of 
no  great  difficulty,  even  if  before  its  application  flexion  had  not  begun 
to  take  place. 

In  generally  contracted  flattened  pelves,  it  is  desirable  that  the 
head  should  be  transverse  and  well  flexed,  with  the  posterior  parietal 
bone  at  least  three  fifths  of  an  inch  below  the  promontory.  With  the 
forehead  and  occiput  resting  upon  the  side-walls  of  the  pelvis,  the 
sagittal  suture  near  the  promontory,  and  an  ear  felt  behind  the 
symphysis  pubis,  the  prospects  of  forceps  operations  are  extremely 
dubious. 

In  justo-minor  pelves  of  moderate  extent  (conjugate  three  and  a 
half  inches),  the  failure  of  the  pains,  which  forms  the  necessity  for 
forceps,  is  rather  the  result  of  the  paralyzing  effect  of  the  pressure  of 
the  bony  canal  upon  the  entire  circumference  of  the  cervix  than  of 
the  absolute  degree  of  pelvic  contraction.  The  heads  descends  in  a 
state  of  complete  flexion,  with  the  large  fontanelle  at  the  pelvic  brim. 
If,  as  the  head  advances,  the  small  fontanelle  moves  from  the  median 
line,  and  the  large  fontanelle  becomes  accessible  to  the  finger,  it  is 

Litzmann,  "  Uobcr  die  Bchandlung  dcr  Gcburt  bei  cngem  Bccken,"  Volkmann's 
"  Samnil.  klin.  Vortr.,"  pp.  715  scq. 


TREATMENT  OF  CONTRACTED  PELVES. 


479 


likely  that  the  pelyis  widens  toward  the  outlet.  If  the  forceps  serves 
only  to  bring  the  fontanelle  down  still  deeper,  and  to  increase  the 
declivity  of  the  sagittal  suture,  the  opposite  condition  obtains,  which 
may  frustrate  the  delivery.* 

In  flattened  pelves  the  forceps  should  be  applied  as  nearly  as  pos- 
sible to  the  fronto-occipital  diameter  of  the  head,  as  the  latter  needs 
to  descend  into  the  transverse  diameter  of  the  pelvis.  "When  applied 
obliquely  it  tends  to  cause  premature  rotation,  which  increases  the 
difficulties  of  extraction.  In  justo-minor  pelves  the  direction  of  the 
blades  is  of  less  importance,  as  the  head  often  descends  spontaneously 
in  an  oblique  diameter.  Success  in  high  forceps  operations  depends 
upon  the  degree  of  accuracy  with  which  the  tractions  are  made  in  the 
axis  of  the  pelvis.  With  the  long-curved  forceps,  it  is  especially  dif- 
ficult to  fulfill  this  requirement  at  the  superior  strait.  Even  when  the 
directions  to  draw  vertically  downward  are  faithfully  carried  out,  a 
considerable  portion  of  the  force  is  expended  in  the  pressure  of  the  for- 
ceps upon  the  soft  tissues  lying  between  them  and  the  anterior  pelvic 
wall.  In  careless  hands  this  pressure  is  capable  of  inflicting  a  great 
deal  of  injury,  particularly  where  the  blades  of  tiie  forceps  are  passed 
within  an  imperfectly  dilated  cervix,  and  where  they  project  somewhat 
beyond  the  child's  head.  Various  devices  have  been  invented  to  cor- 
rect this  defective  working  of  the  instrument.  Pajot  recommends 
placing  the  left  hand  upon  the  lock  to  make  pressure  backward,  while 
with  the  right  hand  tractions  are  made  downward  and  somewhat  for- 
ward. I  have  generally  succeeded  by  exerting  a  small  amount  only  of 
force  at  each  traction,  watching  at  the  same  time  with  great  care  the 
direction  of  the  blades  in  the  pelvis.  This  method  is  pretty  safe,  and 
in  the  end  generally  successful,  but  often  requires  a  very  considerable 
outlay  of  time  and  patience.  A  pair  of  straight  forceps,  as  recom- 
mended Dr.  I.  E.  Taylor,  will  often  enable  one  to  draw  more  directly 
in  the  axis  of  the  brim,  and  will  succeed  when  the  curved  forceps 
have  had  to  be  abandoned.  Of  late  I  have  been  in  the  habit  of  using 
Tarnier  forceps  in  high  operations,  and  am  able  to  give  it  my  cordial 
apiiroval.  The  blades  always  swing  in  the  tranverse  diameter  of  the 
pelvis,  while  the  traction  force  is  exerted  as  nearly  as  possible  upon 
the  center  of  the  child's  head.  A  few  trials  will  convince  the  most 
prejudiced  opponent  of  the  Tarnier  forceps  that  it  will  at  the  supe- 
rior strait  bring  the  head  to  the  floor  of  the  pelvis  in  much  less  time, 
and  with  a  less  expenditure  of  force,  than  can  be  accomplished  by  other 
methods. 

The  dangers  from  the  forceps  in  contracted  pelves  are  due  not 
so  much  to  the  pressure  it  makes  directly  upon  the  child's  head  and 
the  pelvic  walls  as  to  the  compensatory  bulging  of  the  head  in  its 
transverse  diameter.    When  the  head  is  fixed  at  the  brim  and  the  for- 

*  LiTZMANN,  "  Uebcr  die  Bchandlung  der  Geburt  bei  engem  Becken." 


480 


THE  PATHOLOGY  OF  LABOR. 


ceps  is  applied  to  the  forehead  and  occiput,  it  is  evident  that  the  only 
change  of  form  that  can  take  place  is  in  a  vertical  direction.  Safety 
in  delivery  requires  that  there  should  be  no  sudden  augmentation 
of  the  bilateral  pressure,  which  would  necessarily  deepen  the  furrow 
made  by  the  promontory  upon  the  posterior-lying  parietal  bone,  and 
imperil  the  integrity  of  the  maternal  tissues  confined  at  the  conjugate 
between  the  promontory  and  the  pubes.  Until,  therefore,  the  head 
has  passed  the  narrow  strait,  tractions  should  be  made  with  moderate 
force,  and  with  short  periods  of  intermittence.  After  the  head  has 
once  descended  to  the  floor  of  the  pelvis  the  forceps  should  be  removed, 
and  the  head  be  allowed  to  rotate  into  the  conjugate,  then  a  forceps  of 
any  pattern  may  be  adjusted  to  the  sides  of  the  head  should  further 
aid  be  required  to  complete  delivery. 

So  far  we  have  considered  cases  in  which  the  cervix  was  suf- 
ficiently if  not  completely  dilated  before  rupture  of  the  membranes. 
If,  as  is  very  common,  the  membranes  rupture  prematurely,  the  diffi- 
culties and  risks  to  both  mother  and  child  are  greatly  increased.  With 
mixture  come,  as  we  have  already  seen,  escape  of  the  amniotic  fluid, 
retraction  of  the  uterus,  and  interference  in  the  utero-placental  cir- 
culation. With  an  undilated  os  externum  the  cervix  is  stretched  by 
the  head,  and  its  thinned  tissues  are  subjected  to  pressure  from  the 
symphysis  and  promontory.  Delay  leads  to  arrest  of  circulation  and 
necrosis  at  the  points  of  pressure,  but  here  version  and  forceps  are 
alike  impracticable.  This  leaves  as  the  only  alternatives  perforation 
and  the  Oaesarean  section.  Timely  aid,  therefore,  in  such  cases  should 
be  extended  before  a  dangerous  condition  is  reached.  My  first  prefer- 
ence just  after  rupture  is  the  Barnes  dilator,  which  not  only  serves  to 
expand  the  cervix,  but,  when  employed  promptly,  helps  to  prevent 
the  escape  of  the  amniotic  fluid.  JSText  to  the  Barnes  dilator,  and  of 
special  utility  when  the  waters  have  already  escaped,  I  would  place 
the  long,  narrow-bladed  forceps  of  Dr.  Taylor  for  introduction  through 
the  undilated  os.  With  it  the  head  can  be  grasped,  and,  when  made 
to  descend  and  then  allowed  to  recede  in  alternation,  oftentimes  the 
rounded  cranial  surface  will  efficiently  act  as  a  dilating  body,  and  se- 
cure such  a  degree  of  expansion  as  will  pave  the  way  for  the  safe 
adoption  of  other  methods  of  delivery. 


RARE  FORMS  OF  PELVIC  DISTORTION. 


481 


CHAPTER  XXVII. 

BARE  FORMS  OF  PELVIC  DISTORTION. 

The  Xaegele  oblique  pelvis :  morbid  anatomy,  etiology,  diagnosis,  mechanism  of  labor  in, 
prognosis,  treatment. — The  kyphotic  pelvis :  morbid  anatomy,  etiology,  diagnosis, 
prognosis, — Scolio-rachitic  pelvis:  anatomical  characters. — Robert's  pelvis:  anato- 
my, etiology,  diagnosis,  prognosis. — Spondylolisthetic  pelvis :  anatomical  characters, 
diagnosis,  prognosis. — Funnel-shaped  pelvis. — Osteomalacia. — Pelvis  narrowed  by 
exostoses. — Divided  symphysis. 

I.  The  Naegele  Oblique  Pelvis. 

This  variety  of  deformed  pelvis  derives  its  name  from  the  author 
who  first  systematically  studied  it  and  called  attention  to  its  impor- 
tance as  a  cause  of  obstructed  labor. 

Morbid  Anatomy. — The  pathological  characters  peculiar  to  this  va- 
riety of  deformed  pelvis  are,  according  to  the  classical  description  of 
Kaegele,*  the  following  :  1.  Complete  anchylosis  of  one  sacro-iliac 


Fig.  209.— Naegele  oblique  pelvis.    (From  specimen  in  the  Wood  Museum.) 


synchondrosis,  or  osseous  union  between  the  sacrum  and  one  os  innomi- 
natum.  2.  Destruction  or  defective  development  of  the  lateral  half  of 
the  sacrum  and  smaller  caliber  of  the  anterior  sacral  foramina  on  the 
anchylosed  side.  3.  Diminished  breadth  of  the  os  innominatum  and  of 
the  sacro-sciatic  notches  on  the  same  side.  The  articular  facet  of  the  ili- 
um, which  corresponds  to  the  sacral  auricular  surface,  is  less  elongated 
than  on  the  non-anchylosed  side.  4.  The  sacrum  is  displaced  toward 
the  anchylosed  side,  and  its  anterior  surface  is  turned  in  that  direction. 
The  pubic  symphysis  is  pushed  to  the  healthy  side,  and  is,  therefore, 
not  directly  opposite  the  promontory.  5.  The  internal  surface  of  the 
OS  innominatum  on  the  deformed  side  is  flatter  than  the  correspond- 

*  Naegele,  "Das  schragverengtes  Becken,"  Mainz,  1850,  p.  7. 
31 

y 


482 


THE  PATHOLOGY  OF  LABOR. 


ing  sound  bone,  and  the  li7iea  ilio-pedinea  is  but  slightly  curved. 
6.  The  sound  side  of  the  pelvis  is  not  of  an  entirely  natural  shape,  as 
is  shown  by  the  fact  that  its  ilio-pectineal  line  is  straighter  posteriorly, 
and  more  curved  anteriorly,  than  in  a  normal  pelvis.  7.  The  results 
of  the  deformities  mentioned  are  : 

{a)  That  the  pelvis  is  contracted  in  that  oblique  diameter  meas- 
ured by  a  line  passing  from  the  acetabulum  of  the  anchylosed  side  to 
the  opposite  sacro-iliac  joint,  while  the  other  oblique  diameter  is  not 
shortened,  but  even  elongated  in  extreme  cases,  {h)  That  the  dis- 
tances between  the  promontory  and  either  acetabulum,  and  those  be- 
tween the  apex  of  the  sacrum  and  the  spine  of  either  ischium,  measured 
from  the  affected  side,  are  less  than  the  corresponding  distances  on  the 
other,  {c)  That  the  distances  between  the  tuber  ischii  of  the  anchy- 
losed side  and  the  posterior  superior  spinous  process  of  the  opposite 
ilium,  and  those  between  the  spine  of  the  last  lumbar  vertebra  and  the 
anterior  superior  spinous  process  of  the  diseased  side,  are  shorter  than 
the  corresponding  distances  on  the  opposite  side,  {d)  That  the  distance 
of  the  superior  posterior  iliac  spine  of  the  anchylosed  side  from  the 
lower  border  of  the  symphysis  pubis  is  greater  than  that  between  the 
symphysis  and  the  opposite  posterior  superior  spinous  process,  (e)  That 
the  walls  of  the  pelvic  cavity  converge  below,  and  that  the  pubic  arch 
is  narrowed  and  approximated  to  the  type  of  the  male  arch.  (/)  That 
the  acetabulum  of  the  flattened  side  is  directed  farther  forward  than  is 
normal,  while  the  opposite  acetabulum  looks  almost  directly  outward. 
We  may  add  that  the  anterior  surfaces  of  the  bodies  of  the  lumbar  ver- 
tebrae are  directed  toward  the  anchylosed  side.  The  ilium  is  higher, 
steeper,  flatter,  and  reaches  farther  backward  on  that  side.  The  pubic 
arch  looks  toward  the  flattened  side.  The  conjugata  vera  is  somewhat 
elongated.  The  transverse  diameter  is  shortened  at  the  inlet,  and  its 
shortening  progressively  increases  as  the  outlet  is  approached.*  The 
OS  innominatum  of  the  healthy  side  is  somewhat  displaced  outward, 
and  is  more  markedly  curved,  hence  the  venter  of  the  corresponding 
ilium  is  directed  more  anteriorly  than  that  of  the  anchylosed  side.f 
The  deformity  is  most  apparent  at  the  inlet,  which  is  compared  by 
Naegele  to  an  oblique  oval  figure.  The  tuber  ischii  on  the  anchylosed 
side  is  higher,  and  directed  more  posteriorly  and  internally  than  nor- 
mal. This  description  will  also  apply  to  the  ordinary  oblique-ovate 
pelvis,  except  so  far  as  the  anchylosis,  which  is  the  distinguishing 
feature  of  the  Naegele  oblique,  is  concerned. 

Etiology. — The  essential  cause  of  oblique-ovate  pelvis  in  general 
is  continuous  pressure  directed  against  one  of  its  lateral  halves,  the 
weight  of  the  trunk  falling  predominantly  or  exclusively  upon  the 
lower  extremity  of  the  deformed  side,  and  leading  to  displacement  and 

*  ScHROEDER,  "  Lehi  b.,"  p.  596. 

f  LiTZMANN,  "  Die  Formen  d.  Beckens,"  Berlin,  1861,  p.  69. 


RARE  FORMS  OF  PELVIC  DISTORTION. 


483 


distortion  of  the  pelvic  bones.  The  conditions  producing  this  pre- 
dominant unilateral  pressure  are  tabulated  by  Litzmann  *  as  follows  : 
1.  Lateral  spinal  curvature,  usually  of  rachitic  origin.  2.  Impeded  or 
entirely  abrogated  function  of  one  lower  extremity.  In  this  case  the 
deformity  will  affect  that  side  the  lower  extremity  of  which  is  intact,  f 
The  impairment  or  loss  of  function  may  result — (a)  from  unilateral 
hip-disease  ;  (b)  from  amputation  of  one  lower  extremity ;  (c)  from 
an  old  dislocation  of  the  femur  upward  and  backward.  3.  Unsym- 
metrical  sacrum,  produced  by  defective  development,  or  by  atrophy  of 
one  sacral  lateral  mass — (a)  as  the  result  of  a  defect  in  the  original 
formation  ;  (b)  as  the  result  of  abnormal  coalescence  of  the  sacrum 
and  ilium  in  early  life,  whereby  the  growth  of  both  was  hindered  ;  (c) 
as  the  result  of  a  loss  of  substance  from  caries.  Spiegelberg  |  calls 
attention  to  Lambl's  statement  that  primary  asymmetry  of  the  sa- 
crum may  be  due  to  coalescence  of  the  sacral  lateral  masses  and  the 
transverse  processes  of  the  last  lumbar  vertebra,  whereby  the  outward 
growth  of  the  former  is  impeded.  He  also  emphasizes  *  the  fact  that 
simple  chronic  arthritis  of  the  sacro-iliac  synchondrosis  produces  sa- 
cral asymmetry,  without  anchylosis,  by  inducing  contraction  and  atro- 
phic sclerosis  of  the  contiguous  osseous  tissue.  The  continued  use  of 
one  shortened  lower  extremity  is  another  cause  of  excessive  pressure 
upon  the  corresponding  side  of  the  pelvis.  When  this  condition,  ob- 
tains, the  deformity  will  be  on  the  side  of  the  shortening.  The  sacro- 
iliac synostosis,  which  has  been  alluded  to  as  the  distinguishing  char- 
acteristic of  the  Naegele  oblique,  as  contrasted  with  the  other  forms  of 
the  oblique-ovate  pelvis,  is  sometimes  the  primary  deformity,  as  will  be 
seen  from  the  foregoing  etiological  table.  The  coalescence  of  the  joint- 
surfaces  is  never,  however,  congenital,  because  the  articulation  is  fully 
formed  before  the  appearance  of  the  centers  of  ossification  for  the  sa- 
cral lateral  masses.  Nor  can  the  synostosis  be  referred  to  involvement 
of  the  joint-surfaces  in  the  process  of  ossification,  since  this  does  not 
occur  in  any  true  joint.  The  disai^pearance  of  the  joint-cavity  must, 
therefore,  be  referable  to  an  inflammatory  process,  resulting  in  adhe- 
sion of  the  opposed  articular  surfaces.  The  inflammation  may  be  either 
of  traumatic  or  of  strumous  origin.  The  results  of  unilateral  pressure 
upon  the  pelvis  will  depend  upon  the  amount  of  pressure  exerted,  the 
resistance  of  the  bones,  and  the  firmness  of  their  connections. 

Diagnosis. — The  attention  of  the  obstetrician  will  be  directed  to 
the  possibility  of  the  existence  of  the  oblique-ovate  pelvis  when  the 
subject  limps  and  presents  an  inequality  in  the  height  of  the  hips  or 
evidences  of  antecedent  gluteal  abscesses.  The  diagnosis  is  assured  by 
a  physical  examination,  which  shows,  in  the  first  place,  the  distance 

*  Litzmann,  op.  cit.,  p.  68.     f  Gusserow,  "Arch.  f.  Gynaek.,"  Bd.  xi,  1877,  p.  264. 
X  Spiegelberg,  "  Lehrb.,"  p.  475. 

*  Spiegelberg,  "  Arch.  f.  Gynaek.,"  ii,  1871,  pp.  159  et  seq. 


484 


THE  PATHOLOGY  OF  LABOR. 


between  the  spinous  process  of  the  last  lumbar  vertebra  and  the  pos- 
terior superior  spinous  process  to  be  considerably  less  on  the  deformed 
than  on  the  healthy  side.  The  absence  of  this  sign  is,  however,  no 
proof  of  the  non-existence  of  the  deformity.  The  distorted  ilium  is 
higher  than  the  other,  and  projects  farther  posteriorly  than  is  normal. 
A  vaginal  examination  reveals  the  straight  course  of  the  ilio-pectineal 
line  on  the  side  of  the  anchylosis,  the  deviation  of  the  sub-pubic  arch 
toward  that  side,  a  disparity  in  the  distances  between  the  ischiatic 
spines  and  the  apex  of  the  sacrum,  and  the  deviation  of  the  promon- 
tory. Naegele*  suggested,  for  the  completion  of  the  diagnosis,  the 
application  of  the  following  measurements,  which  are  equal  on  both 
sides  in  the  normal,  but  different  in  the  oblique-ovate  pelvis  :  1.  The 
distance  of  the  tuber  ischii  of  one  side  from  the  posterior  superior 
iliac  spine  of  the  other  ;  on  the  deformed  side  it  is  shorter.  2.  That 
from  the  anterior  superior  to  the  posterior  superior  spine  of  the  other 
side  ;  shorter  from  the  anterior  spine  of  the  deformed  side.  3.  That 
from  the  spine  of  the  last  lumbar  vertebra  to  the  anterior  superior 
spinous  process  of  the  same  side  ;  less  on  the  contracted  side.  4.  That 
from  the  trochanter  major  to  the  opposite  posterior  superior  spinous 
process  ;  shorter  when  measured  from  the  affected  side.  5.  That  from 
the  under  surface  of  the  symphysis  pubis  to  the  posterior  superior 
iliac  spine ;  longer  on  the  narrowed  side.  These  measurements  are 
only  of  avail  in  well-marked  cases,  and  may  lead  to  erroneous  con- 
clusions if  other  diseases  of  the  bones  be  simultaneously  present. 
The  vaginal  examination  affords,  on  the  whole,  the  most  accurate 
results. 

Mechanism  of  Labor. — The  mechanism  of  the  birth,  in  an  oblique- 
ovate  pelvis,  is  the  following  :  If  the  promontory  be  retreating,  the 
sagittal  suture  of  the  fetal  cranium  enters  the  inlet  parallel  to  the 
longer  oblique  diameter.  If,  however,  the  promontory  project  con- 
siderably, and  is  closely  approximated  to  the  ilium  of  the  affected  side, 
no  portion  of  the  head  can  be  admitted  between  them,  f  The  cranium 
will  then  enter  the  pelvis  most  easily  with  the  sagittal  suture  in  the 
short  oblique  diameter,  and  will  pass  through  the  pelvic  canal  without 
rotation.  If  the  pelvis  be  originally  small  and  the  deformity  marked, 
the  obstruction  to  labor  may  be  complete.  Should  the  pelvis,  how- 
ever, be  roomy  and  the  promontory  retreating,  no  considerable  impedi- 
ment will  be  offered  to  parturition. 

Prognosis. — It  is  obvious  that  the  prognosis,  for  both  mother  and 
child,  is  best  when  the  pelvis  was  originally  large,  and  far  less  favor- 
able under  the  reversed  condition.  In  the  latter  case  the  mother  very 
frequently  succumbs  and  the  child  is  only  rescued  by  the  Caesarean 
section.    Litzmann^s  I  statistics  report  the  death  of  twenty-two  out  of 

*  Nafgele,  op.  cit.,  p.  174. 

f  LiTZMANN,  "Monatsschr.  f.  Gcburtsk.,"  xxiii,  1864,  p.  268.  X  ^^'^-^  P-  284. 


RARE  FORMS  OF  PELVIC  DISTORTION. 


485 


twenty-eight  mothers,  five  of  whom  perished  undelivered,  and  that  of 
thirty-one  children  out  of  forty-one  cases.  These  figures  by  no  means, 
however,  fairly  represent  the  average  result,  since  many  cases  of  slight 
and  moderate  deformity  escape  detection. 

Treatment. — In  a  case  of  extreme  obliquity  at  the  Bellevue  Hospi- 
tal, where  the  distance  between  the  ischia  barely  exceeded  two  inches, 
I  induced  premature  labor  at  presumably  the  twenty-ninth  week.  The 
child  was  turned  and  lived  long  enough  after  extraction  to  receive 
the  rite  of  baptism.  The  mother  made  a  speedy  recovery.  This  case 
affords  a  striking  contrast  to  those  reported  by  Litzmann.  Undoubt- 
edly, if  the  obliquity  were  always  recognized  at  a  sufficiently  early 
period  of  pregnancy,  the  induction  of  premature  labor  would  favorably 
change  the  prognosis.  Very  commonly,  however,  the  condition  passes 
unperceived  until  delay  in  labor  leads  to  a  more  careful  investigation. 
In  such  cases,  if  the  head  has  entered  the  pelvic  cavity,  and  the  dimi- 
nution of  the  space  between  the  ischia  is  not  excessive,  a  careful  at- 
tempt should  be  made  with  the  forceps  to  tesfe  the  adaptability  of  the 
presenting  part  to  the  contracted  diameter.  Violent  tractions  should, 
however,  be  avoided.  Studley  *  has  recently  reported  a  case  of  coxal- 
gic  oblique  pelvis  in  which  fracture  of  the  pubic  rami  upon  the  right 
side  resulted  from  forceps  delivery.  If  the  disproportion  is  such  that 
moderate  tractions  are  unavailing  to  advance  the  head,  or  if  the  child 
is  already  dead,  perforation  should  be  performed.  Craniotomy  at  the 
inferior  strait  is  much  less  dangerous  than  at  the  brim. 

If  the  head  fail  to  enter  the  pelvis,  we  have  to  inquire  whether  the 
result  be  due  to  absolute  deficiency  of  the  pelvic  space,  or  to  the  fact 
that  the  sagittal  suture  of  the  head  corresponds  to  the  shortened  ob- 
lique diameter.  In  the  first  event  the  case  becomes  a  good  one  for 
laparo-elytrotomy,  while  in  the  second  version  should  be  performed 
with  a  view  to  bringing  the  long  cephalic  diameter  into  correspond- 
ence with  the  opposite  longer  diameter  of  the  pelvis.  If  extraction  is 
then  found  to  be  impossible,  perforation  can  still  be  performed  upon 
the  after-coming  head. 

II.  The  Kyphotic  Pelvis. 

Morbid  Anatomy. — The  characteristic  deviations  of  a  kyphotic  pel- 
vis from  the  normal  type  are  due  to  the  unnatural  direction  in  which 
the  weight  of  the  superimposed  trunk  is  communicated  to  the  base  of 
the  sacrum,  as  the  result  of  an  existing  antero-posterior  spinal  cur- 
vature. If  a  dorsal  kyphosis  be  entirely  compensated  by  a  lumbar 
lordosis,  the  former  may  entail  no  pelvic  distortion.  As  a  rule,  the 
deformity  is  most  marked  with  lumbar  and  sacral  kyphoses,  which 
admit  of  no  compensatory  lordosis,  and  least  apparent  with  remote  dor- 
sal kyphoses.   The  effect  of  the  altered  direction,  in  which  the  weight  of 

*  "  Am.  Jour,  of  Obstet.,"  1879,  p.  269. 


486 


THE  PATHOLOGY  OF  LABOR. 


the  trunk  is  transmitted  to  the  sacrum,  is  to  force  the  latter  more  deeply 
between  the  ossa  innominata  and  to  rotate  its  upper  portion  in  a  pos- 
terior direction.  The  displacement  backward  of  the  inferior  extremity 
of  the  trunk  causes  the  center  of.  gravity  to  be  thrown  far  behind  the 

  acetabula,  and  produces  a 

consequent  diminution  in  the 
obliquity  of  the  pelvis  by  ele- 
\^ating  the  anterior  pelvic  pa- 
rietes.*  The  change  in  the 
pelvic  obliquity  is  antago- 
nized by  the  ilio-femoral  liga- 
ments, and  the  result  of  these 
opposingforcesf  is  asfollows  : 
The  sacrum  is  narrowed  and 
elongated  by  the  traction 
from  behind  and  above,  and 
its  upper  part  is  displaced 
backward.  Its  transverse  con- 
cavity is  increased  and  its 
longitudinal  concavity  dimin- 
ished. J;  The  bodies  of  the 
sacral  vertebrae  are  on  a  plane 
posterior  to  their  transverse 
processes.    The  promontory 

Fig.  210.— Specimen  of  kyphotic  pelvis.  (Litzmann.)    is  high   and  is  directed  far 

backward.  The  upper  ante- 
rior surface  is  sometimes  convex  while  the  concavity  of  the  lower  part 
is  preserved,  and  an  S-like  shape  is  thus  imparted  to  the  sacral  curve. 
The  higher  anterior  sacral  foramina  look  upward.  Owing  to  the  ten- 
sion of  the  ilio-femoral  ligaments,  the  anterior  inferior  spinous  pro- 
cesses of  the  ilium  are  well  developed.  The  linem  ilio-pectinem  are 
only  slightly  curved.  The  sub-pubic  arch  is  narrowed.  The  spines 
and  tuberosities  of  the  ischia  are  abnormally  approximated.  Owing 
to  the  narrowness  of  the  sacrum,  the  posterior  superior  iliac  spines  are 
in  close  proximity  to  each  other,  while  the  spines  and  crest  of  the 
ilium  are  more  remote  than  in  a  normal  pelvis.  The  venters  of  the 
ilia  are  expanded  and  directed  to  the  front.  The  transverse  diameter 
of  the  false  pelvis  is,  therefore,  increased,  while  that  of  the  true  pelvis 
is  diminished.  The  symphysis  is  prominent,  the  horizontal  pubic 
rami  meeting  at  an  acute  angle.  At  the  inlet  the  oblique  and  the 
conjugate  diameters  are  elongated  and  the  transverse  diameter  cur- 
tailed.   In  the  true  pelvis  the  transverse  diameters  are  considerably, 

*  Lange,  "Arch.  f.  Gynack.,"  Bd.  i,  ISYO,  p.  231. 
f  Si'iEGELHEUG,  "Lehrbuch,"  p.  483. 

X  BuESLAU,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxvii,  1SG6,  p.  319. 


RARE  FORMS  OF  PELVIC  DISTORTION. 


487 


and  the  antero-posterior  diameter  slightly  shortened.  These  diame- 
ters become  still  more  contracted  as  the  outlet  is  approached.*  If  a 
lumbo-sacral  kyphosis  be  present,  the  sacrum  is  shortened  and  very 
narrow.  If  this  kyphosis  be  situated  very  low  down,  it  may  be  com- 
pensated for  by  a  low  lumbar  lordosis,  which  overhangs  and  materially 
contracts  the  pelvic  inlet,  f 

Etiology. — The  cause  of  the  spinal  curvature  resulting  in  kyphotic 
pelvis  is  usually  caries  of  the  vertebrae.  J; 

Diagnosis. — The  antecedent  history  and  the  discovery  of  kyphosis 
will  render  the  existence  of  this  form  of  pelvis  probable.  On  more 
careful  physical  examination,  the  shape  and  position  of  the  sacrum, 
the  short  interval  between  the  spines  and  the  tuberosities  of  the  is- 
chium and  the  posterior  superior  iliac  spines,  the  wide  separation  of  the 
anterior  superior  iliac  spines,  the  narrow  pubic  arch  and  prominent 
symphysis,  the  flatness  of  the  iliac  venters,  and  the  difficulty  experi- 
enced in  reaching  the  promontory,  will  establish  the  diagnosis.  The 
differential  diagnosis  between  a  kyphotic  pelvis  and  one  deformed  by 
osteomalacia,  with  which  it  is  sometimes  confounded,  will  be  readily 
made  by  reference  to  these  distinctive  features  and  to  the  fact  that 
the  transverse  diameters  of  the  false  pelvis  are  elongated  in  a  kyphotic 
pelvis,  the  reverse  obtaining  in  osteomalacia. 

Prognosis. — The  amount  of  obstruction  offered  to  parturition  will 
naturally  depend  upon  the  grade  of  the  pelvic  contraction.  The 
prognosis  for  the  mother  is  not  exceedingly  grave  unless  the  outlet 
be  extremely  contracted.  The  prospects  for  the  preservation  of  the 
child's  life  are  unfavorable.  In  some  instances  there  is  said  to  be  a 
certain  amount  of  mobility  in  the  pelvic  joints,  which  enlarges  the 
outlet  and  facilitates  the  parturient  process. 

Treatment. — Dr.  I.  E.  Taylor  has  recently  reported  a  case  of  ex- 
treme pelvic  kyphosis,  where  the  distance  between  the  ischia,  measured 
by  me  with  great  care,  did  not  exceed  one  inch  and  three  fourths.  In 
the  patient's  first  pregnancy  he  delivered  her  by  craniotomy.  She 
was  out  of  bed  on  the  tenth  day.  At  her  second  confinement.  Dr. 
Taylor  resorted  to  Porro's  operation,  with  a  view  to  saving  the  life 
of  the  child.  The  latter  object  was  accomplished,  and  the  woman 
lived  twenty-one  days,  but  died  eventually  of  pulmonary  embolism 
following  phlegmasia.  It  is  obvious  that  in  this,  as  in  all  other 
forms  of  pelvic  contraction,  the  treatment  will  be  determined  by 
the  extent  of  the  deformity.  In  the  extreme  grades,  however,  the 
comparatively  favorable  results  of  craniotomy,  when  performed  after  the 
head  has  entered  the  pelvic  cavity,  would,  except  for  the  interests  of  the 
child,  give  to  that  operation  the  preference  over  the  CsBsarean  section. 

*  HuTER,  "Ztschr.  f.  Gcburtsh,  u.  Gynaek.,"  Bd.  v,  1880,  p.  22. 
\  Fehling,  "Arch.  f.  Gynaek.,"  Bd,  iv,  187?.,  p.  2. 
^    X  Neugebauer,  "Monatsschr.  f.  Gcburtsk.,"  Bd.  xxii,  1863,  p.  297. 


488 


THE  PATHOLOGY  OF  LABOR. 


III.   SCOLIO-RACHITIC  PeLVIS. 

A  brief  allusion  must  be  made  to  the  anatomical  characteristics  of 
a  purely  rachitic  pelvis,  in  order  to  render  the  differences  between  it 
and  a  scolio-rachitic  pelvis  intelligible.  The  leading  pathological 
features  of  the  infantile  rachitic  pelvis  consist  in  expansion  of  the  sub- 
pubic arch,  prominence  and  lowering  of  the  promontory,  widening  and 
elongation  of  the  sacrum,  flatness  of  the  venters  of  the  ilia,  between 
which  there  is  an  abnormally  wide  interval,  and  in  an  irregularly 
rounded,  triangular,  or  kidney-shaped  pelvic  inlet.*  These  anatomical 
features  are  not  altered  by  the  supervention  of  a  scoliosis,  but  the 


half  of  the  pelvis  and  in  the  counter-pressure  exerted  upon  its  ar- 
ticular surface.  The  contracted  half  of  the  pelvis  is  higher  and 
more  inclined  than  its  fellow.  The  sacrum  has  sunk  deep  between 
the  ilia,  and  is  narrower  upon  the  side  of  the  lumbar  scoliosis.  The 
sacral  vertebral  bodies  are  sometimes  displaced  forward,  project- 
ing beyond  the  lateral  masses.  The  promontory  is  displaced  toward 
the  contracted  side,  and  the  corresponding  lateral  mass  is  often 
narrowed.    There  is  rarely  anchylosis  of  the  hip-joint.    The  ilium 

*  Fehling,  "  Arch.  f.  Gynack.,"  Bd.  x,  1876,  p.  1  ;  Ibid.,  Bd.  xi,  1877,  p.  173. 
I  Kehrer,  "Arch.  f.  Gynaek.,"  Bd.  v,  1873,  p.  60. 

t  Leopold,  "Das  skoliotisches  und  kyphotisch-rachitisches  Becken,"  Leipsic,  1879, 


latter  adds  to  the  deformity  al- 
ready existing  its  own  patho- 
logical characters.  The  latter 
combine  to  produce  a  marked 
unilateral  asymmetry  of  the 
pelvis,  f  The  most  ordinary 
form  of  scoliosis  consists  in  a 
deviation  of  the  dorsal  vertebraB 
to  the  right  and  a  compensa- 
ting lumbar  curve  to  the  left. 


Fig.  211.— Specimen  of  scolic-rachitic  pelvis. 
(Litzmann.) 


The  adult  scolio-rachitic  pel- 
vis presents  many  points  of  re- 
semblance to  the  infantile,  its 
leading  peculiarities  being  the 
following  :  X  The  entire  pelvis 
is  inclined  toward  the  side  of 
the  lumbar  curve,  and  rests 
chiefly  upon  the  corresponding 
thigh.  The  cause  of  the  pelvic 
asymmetry  is  to  be  sought  in 
the  increased  weight  thus 
thrown  upon  the  contracted 


p.  7. 


RARE  FORMS  OF  PELVIC  DISTORTION. 


489 


s  erect,  looks  inward,  and  is  narrowed  antero-posteriorly.    Its  crest 
's  higher  than  that  of  the  opposite  side.     The  symphysis  is  dis- 
laced  toward  the  uncontracted  half  of  the  pelvis.    The  ilio-pectineal 
ine  makes  a  sharp  curve  inward  near  the  sacro-iliac  synchondrosis, 
nd  then  pursues  an  undulatory  course  to  the  symphysis,  being  notably 
bent  inward  opposite  the  acetabulum.    On  the  uncontracted  side  the 
"orresponding  line  forms  a  large  and  rounded  arch.    The  tuber  ischii 
n  the  side  of  the  lumbar  scoliosis  is  turned  outward.    The  oblique 
iameter  of  this  side  is  greater,  but  the  distance  between  the  sacrum 
nd  the  acetabulum  (distantia  sacro-cotyloidea)  is  much  shorter  than 
n  the  uncontracted  side.    The  plane  of  the  inlet  is  obliquely  cordi- 
orm,  being  contracted  upon  the  side  of  the  lumbar  scoliosis  and  ex- 
panded on  the  other.    Exactly  the  reverse  conditions  obtain  at  the 
elvic  outlet.*    The  conjugata  vera  is  notably  sliortened  by  the  pro- 
ruding  promontory.     The  antero-^^osterior  diameter  of  the  outlet, 
although  contracted,  still  far  surpasses  the  conjugata  vera  in  length. 
Other  and  independent  pathological  conditions  may  aggravate  the 
obstruction  caused  by  the  peculiar  deformity  in  question.    Thus,  Hu- 
genberger  describes  a  case  of  scolio-rachitic  pelvis  complicated  by 
an  extensive  sacral  hydrorachis.f 

The  peculiar  deformity  of  a  scolio-rachitic  pelvis  obstructs  de- 
livery by  so  narrowing  the  space  between  the  acetabulum  and  the 
sacrum  as  to  prevent  any  part  of  the  fetal  cranium  from  engaging  in 
it.  Eotation  is  thus  prevented,  and  the  delivery  must  be  accom- 
plished, if  indeed  it  be  possible,  by  the  same  mechanism  obtaining  in 
a  justo-minor  pelvis,  the  conjugata  vera  of  which  would  be  here  rep- 
resented by  the  distantia  sacro-cotyloidea,  and  the  transverse  diameter 
of  which  would  correspond  with  the  oblique  diameter  of  the  uncon- 
tracted side. 

ly.  Egbert's  Anchylosed  and  Transversely  Contracted  Pelvis. 

This  very  rare  form  of  contracted  pelvis  was  first  described  by 
Eobert,  in  1842.  Its  leading  characteristics  are  bilateral  sacro-iliac 
anchylosis,  and  absence  or  rudimentary  development  of  the  sacral 
lateral  masses.  The  sacrum  is  consequently  very  narrow,  and  only 
slightly  wider  ,at  its  upper  than  at  its  lower  extremity.  The  longi- 
tudinal and  transverse  concavities  of  the  bone  are  nearly  or  quite  ob- 
literated. In  some  cases  the  normal  transverse  concavity  is  trans- 
formed into  a  convexity.  The  sacrum  is  deeply  pressed  between  the 
ossa  innominata.  The  posterior  superior  iliac  spines  are,  consequent- 
ly, closely  approximated,  and  the  ilia  project  far  above  the  base  of 
the  sacrum.  The  promontory  encroaches  considerably  upon  the  supe- 
rior strait.  The  iliac  venters  are  flattened  and  directed  anteriorly. 
*  Leopold,  op.  cit,  p.  10. 

f  HuGENBERGER,  "Arch.  f.  Gynack.,"  Bd.  xiv,  p.  1. 


490 


THE  PATHOLOGY  OF  LABOR. 


The  linese  ilio-pectineae  are  slightly  or  not  at  all  curved,  and  abnor- 
mally approximated.    The  descending  rami  of  the  pnbes  imite  at  an 

acute  angle.  The  ischiatic  spines 
and  tuberosities  are  in  close  prox- 
imity to  each  other  and  to  the 
lateral  margins  of  the  sacrum. 
The  dimensions  of  the  pelvis  are 
materially  altered. 

The  transverse  diameter  is  not- 
ably diminished  and  grows  short- 
er from  above  downward,  so  that 
at  the  outlet,  in  marked  cases,  it 
is  represented  by  a  mere  crevice 
between  the  ischia  and  the  pubic 
Fig.  212.— Kobert's  pelvis.  (Lambi.)       bones.    The  form  of  the  inlet  is 

that  of  a  long  and  narrow  wedge 
with  its  apex  directed  anteriorly.  The  average  diameter  of  the  outlet 
is  less  than  two  inches.*  The  antero-posterior  diameter  is  either  of 
normal  length  or  but  slightened  shortened,  since  the  projection  of  the 
promontory  is  compensated  for  by  the  absence  of  the  normal  outward 
curve  of  the  lateral  borders  of  the  inlet.  The  pelvic  canal  is  deeper 
than  in  a  normal  pelvis.  In  some  cases  there  is  asymmetry  of  the  two 
lateral  halves  of  the  pelvis. 

Etiology. — The  decisive  agency  in  the  production  of  the  deformity 
under  consideration  is  the  narrowness  of  the  sacrum,  which  is  chiefly 
due  to  the  diminished  breadth  of  its  lateral  masses,  but  also  in  a  cer- 
tain measure  to  the  small  transverse  diameter  of  the  bodies  of  the 
sacral  vertebrae.  Diversities  of  opinion  prevail  regarding  the  connec- 
tion between  the  narrowness  of  the  sacrum  and  the  sacro-iliac  synos- 
tosis. 

Some  authors  consider  deficient  development  of  the  centers  of  ossi- 
fication of  the  lateral  masses  as  the  primary  event  and  the  anchylosis 
as  dependent  upon  this.  Others  regard  the  synostosis  as  the  primary 
change  which  determines  the  atrophy  of  the  lateral  masses,  f  and  vari- 
ously refer  it  to  inflammatory  processes  or  to  arrested  development.]; 
In  some  cases  it  would  seem  that  the  sacrum  was  originally  of  normal 
breadth,  but  was  narrowed  and  united  with  the  ilium  by  osteitis  and 
arthritis.*  The  transverse  convexity  of  the  anterior  sacral  surface  is 
explained  by  the  fact  that  the  bodies  of  the  vertebrae  are  pressed  for- 
ward by  the  weight  of  the  superimposed  trunk  after  the  union  of  the 
sacral  lateral  masses  with  the  ilia,  and  at  a  time  when  the  connections 

*  Spiegelherg,  "  Lchrbuch,"  p.  482. 

f  LiTZMANN,  "  Die  Formen  des  Bockcns,"  Berlin,  1861,  p.  62. 
X  Kehrer,  "Monatsschr.  f.  Geburtsk.,"  Bd.  xxxiv,  1869,  p.  20. 

*  Kleinwachter,  "Arch.  f.  Gynaek.,"  Bd.  i,  p.  156. 


RARE  FORMS  OF  PELVIC  DISTORTION. 


491 


between  the  bodies  and  the  lateral  masses  are  still  pliable  and  yield- 
ing. The  close  approximation  of  the  ilia  and  their  parallel  course  are 
referable  to  the  narrowness  of  the  sacrum  and  to  increased  lateral 
pressure  upon  the  acetabula.*  The  combined  action  of  these  agencies 
produces  the  narrowness  of  the  sub-pubic  arch,  the  acutely  angular 
junction  of  the  descending  pubic  rami,  the  approximation  of  the  iliac 
crests,  and  the  straight  course  of  the  linese  ilio-peetineae. 

Diagnosis. — The  diagnosis  is  partly  based  upon  the  abnormal  ap- 
proximation of  the  posterior  superior  iliac  spines,  which  almost  cover 
the  deeply  seated  spinous  process  of  the  last  lumbar  vertebra,  and  upon 
a  similar  approximation  of  the  trochanters,  of  the  tubera  ischii,  and  of 
the  iliac  spines  and  crests.  A  vaginal  examination  then  reveals  the 
parallel  course  of  the  descending  pubic  rami  and  the  striking  diminu- 
tion of  the  transverse  diameter.  The  differential  diagnosis  between 
the  Robert  and  the  kyphotic  pelves  is  based  upon  the  absence  of 
a  kyphosis  in  the  former  and  upon  the  striking  difference  between  the 
respective  transverse  diameters. 

Prognosis. — This  is  very  bad  for  the  mother,  inasmuch  as  labor  is 
completely  obstructed  by  the  deformity,  and  operative  interference  is 
always  indicated. 

The  Csesarean  section  offers  the  only  hope  of  preserving  the  child's 
life. 

V.  Spoxdylolisthetic  Pelvis. 

This  rare  form  of  contracted  pelvis  was  first  described  by  Rokitan- 
sky  in  1839.  f  Its  principal  pathological  feature  consists  in  separation 
of  the  last  lumbar  from  the  first  sacral  vertebra  and  in  descent  of  the 
lumbar  spine  into  the  pelvis,  where  the  inferior,  or  in  an  extreme  case 
the  posterior,  surface  of  the  body  of 
the  last  lumbar  rests  upon  the  ante- 
rior surface  of  the  first  sacral  verte- 
bra. The  anterior  surface  of  the  last 
lumbar  vertebra  is  directed  downward. 
The  anterior  surfaces  of  the  fourth, 
third,  and  second  lumbar  vertebrae 
form  an  arch,  the  most  prominent 
part  of  which,  being  nearest  the  sym- 
physis, replaces  the  normal  promon- 
tory. The  result  of  this  displace- 
ment js  a  considerable  diminution  in 
the  aritero-posterior  diameter  of  the     Fig.  2i3.-Spondy]oiistlietic  pelvis. 

^  (Kilian.) 

pelvic  inlet.    The  descent  of  the  lum- 
bar portion  of  the  spine,  which  is  gradually  accomplished,  is  attended 
by  atrophy  of  the  intervertebral  cartilages,  and  frequently  by  osse- 


*  LiTZMANN,  op.  ci(.,  p.  65. 


f  ScHROEDER,  "  Lehrbuc'h,"  p.  574. 


492 


THE  PATHOLOGY  OF  LABOR. 


ous  union  between  the  bodies  of  the  lumbar  and  sacral  vertebraa. 
The  weight  of  the  superimposed  trunk  being  now  transmitted  to 
the  anterior  surface  of  the  sacrum,  instead  of  to  its  base,  the  pel- 
vic center  of  gravity  is  displaced  forward.  This  is  compensated 
for  by  a  diminution  in  the  normal  pelvic  inclination,  the  anterior 
portion  of  the  pelvis  being  tilted  slightly  upward.  The  pressure 
upon  the  anterior  surface  of  the  sacrum  forces  its  base  backAvard. 
The  posterior  superior  iliac  spines  are  thus  widely  separated,  and  the 
apex  of  the  sacrum  is  thrown  forward,  encroaching  upon  the  antero- 
posterior diameter  of  the  outlet.  In  a  case  cited  by  Breslau,*  the 
sacro-iliac  synchondrosis  possessed  great  mobility. 

The  traction  upon  the  ilio-femoral  ligaments,  which  approximates 
the  tubera  ischii,  and  the  lateral  dis^Dlacement  of  the  ilia,  due  to  re- 
cession of  the  sacrum,  produce  a  shortening  of  the  transverse  pelvic 
diameter,  which  becomes  more  marked  in  proportion  as  the  outlet  is 
approached. 

Etiology. — The  original  cause  of  the  deformity  under  considera- 
tion is  separation  of  the  articular  processes  of  the  last  lumbar  from 
those  of  the  first  sacral  vertebra.  This  may  be  effected  by  a  fracture 
of  the  transverse  processes,  as  in  a  case  reported  by  Breisky,f  by  caries 
of  the  transverse  processes,  due  to  traumatism,  I  by  traction  upon  the 
articular  ligaments  sufficient  to  produce  luxation,  or  by  such  an  un- 
usual congenital  separation  of  the  sacral  articular  processes  as  will 
permit  the  corresponding  lumbar  processes  to  glide  between  them. 
The  dislocation  may  occur  immediately  after  birth,  or  after  the  fuller 
development  of  the  trunk.*  The  luxation  is  not  followed  by  paraly- 
sis, because  the  cauda  equina  is  well  protected  by  its  fibrous  invest- 
ments, and  occupies  so  small  a  portion  of  the  sacral  vertebral  canal 
that  it  readily  adapts  itself  to  the  altered  form  of  the  latter  without 
being  subjected  to  injurious  pressure. 

Diagnosis. — Breisky  ||  calls  attention  to  the  peculiar  figure  of  per- 
sons whose  pelves  are  spondylolisthetic.  The  thorax  and  extremities 
are  of  normal  shape,  while  the  abdomen  appears  unusually  short  and 
is  sunken  between  the  prominent  iliac  crests.  The  pelvis  is  but 
slightly  inclined,  and  the  crests  of  the  ilia  are  separated  by  a  wide 
interval.  The  pelvic  inclination  is  lessened,  and  the  gluteal  regions 
are  abnormally  steep.  Olshausen  ^  first  announced  the  fact  that  the 
point  of  division  of  the  abdominal  aorta  into  the  common  iliac  arteries 
is  displaced  downward  by  the  descending  lumbar  vertebrae  to  such  an 

*  Breslau,  "Monatsschr.  f.  Geburtsk.,"  Bd.  xviii,  1861,  p.  411. 
f  Breisky,  "Arch.  f.  Gynaek.,"  Bd.  ix,  1876,  p.  1. 

\  Blasius,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxxi,  1868,  p.  241;  Euder,  "  Monatsschr. 
f.  Geburtsk.,"  Bd.  xxxiii,  1869,  p.  24*7. 

*  Olshausen,  "Monatsschr.  f.  Geburtsk.,"  Bd.  xxii,  1803,  p.  301. 

II  Breisky,  loc.  cii.,  p.  9.     ^  Olshausen,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxiii,  p.  204. 


RARE  FORMS  OF  PELVIC  DISTORTION. 


493 


extent  as  to  enable  the  palpating  finger,  introduced  into  Douglas's  cul- 
de-sac,  to  detect  pulsation  in  these  vessels.  The  same  author*  insists 
upon  the  diagnostic  yalue  of  the  development  at  puberty  of  a  lumbar 
lordosis,  which  is  attended  by  violent  sacral  pains.  Hartmann  \  was 
enabled  to  feel  the  point  of  the  aorta's  division  on  the  upper  border  of 
the  fourth  lumbar  vertebra,  and  Breslau  J  felt  a  pulsating  vessel  in  the 
same  situation.  The  spondylolisthetic  lordosis  may  be  mistaken  for  the 
sacral  deformity  peculiar  to  a  rachitic  pelvis.  Breisky  *  suggests  that 
this  error  may  be  avoided  by  attention  to  the  fact  that  in  the  rachitic 
pelvis  the  sacral  lateral  masses  pass  outward  from  the  projecting  prom- 
ontory, while  in  spondylolisthesis  one  can  feel  at  the  pelvic  inlet  only 
the  rounded  prominence  of  a  single  vertebral  body  without  laterally 
expanding  wings.  The  projecting  angle  made  by  the  body  of  the 
last  lumbar  vertebra  with  the  anterior  surface  of  the  sacrum  is  also 
easily  accessible  to  palpation. 

Prognosis. — The  prognosis  in  a  case  of  spondylolisthetic  pelvis  is 
bad  as  contrasted  with  that  in  pelves  contracted  to  an  equal  degree 
from  other  causes,  because  the  deformity  begins  above  and  extends 
below  the  pelvic  inlet,  instead  of  being  limited  to  a  comparatively 
short  space.  Moreover,  the  outlet  is  more  contracted  than  in  many 
varieties  of  deformed  pelvis.  The  treatment  consists  either  in  the 
induction  of  abortion  or,  at  term,  in  the  performance  of  the  Caesarean 
section. 

VI.   FUNKEL-SHAPED  PeLVIS. 

This  term  has  been  applied  to  two  varieties  of  deformed  pelves, 
both  of  which  are  exceedingly  rare.  The  inlet  of  the  first  variety 
is  either  normal  or  but  slightly  contracted  in  all  its  diameters,  but  its 
canal  is  gradually  and  progressively  narrowed  as  the  outlet  is  ap- 
proached. The  contraction  affects  chiefly  the  transverse  diameter  ; 
but  either  this  alone,  the  antero-posterior  diameter  alone,  or  both  to- 
gether may  be  shortened.  The  lateral  pelvic  walls  converge  consider- 
ably, particularly  in  the  vicinity  of  the  outlet.  The  descending  rami 
of  the  pubic  bones  are  closely  approximated,  so  that  the  sub-pubic 
arch  forms  an  acute  angle.  The  spines  and  tuberosities  of  the  ischia 
are  in  close  apposition.  ||  The  sacrum  is  elongated  and  but  slightly 
curved,  its  position  resembling  that  of  the  sacrum  in  a  kyphotic  pelvis. 
It  will  be  seen  that  these  deformities  produce  a  close  resemblance  to 
the  typical  male  pelvis.  Pelves  of  this  variety  are  frequerftly  some- 
what unsymmetrical. 

*  Olshausen,  "Monatsschr.  f.  Geburtsk.,"  Bd.  xxii,  1863,  p.  301. 
f  IIartmaxn,  *' Monatsschr.  f.  Geburtsk.,"  Bd.  xxv,  1865,  p.  469  ;  Bd.  xxxi,  1868,  p. 
285. 

X  Bre.slau,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xviii,  p.  411.      *  Breisky,  loc.  cit.,  p.  9. 
I  PoppEL,  "Monatsschr.  f.  Geburtsk.,"  Bd.  xxviii,  1866,  p.  224;  Braun,  "Arch.  f. 
Gynack.,"  Bd.  iii,  1870,  p.  154. 


494 


THE  PATHOLOGY  OF  LABOR. 


The  second  variety  of  the  funnel-shaped  pelvis  is  so  exceedingly 
rare  as  to  require  only  a  passing  notice.  In  this  instance  the  deform- 
ity is  exactly  the  reverse  of  that  just  described,  the  inlet  being  very 
narrow  in  either  one  or  in  all  of  its  diameters,  while  the  outlet  is  of 
normal  size  or  even  abnormally  wide  in  one  or  more  directions.* 

Etiology. — The  causes  of  this  deformity  are  imperfectly  under- 
stood. The  former  variety  is  believed  to  be  due  to  arrest  of  develop- 
ment in  the  sacral  lateral  masses  and  to  other  causes  cooperating  to 
alter  the  direction  in  which  the  weight  of  the  trunk  is  normally 
transmitted  to  the  sacrum.  This  view  seems  to  be  confirmed  by 
Schroedcx^'s  observation  that  the  funnel-shaped  pelvis  is  of  unusual 
frequency  in  a  certain  German  province,  where  the  children  are  car- 
ried upon  the  back  in  a  position  intermediate  between  the  erect  and 
the  recumbent  posture,  f  The  weight  of  the  body  would  in  this  case 
be  transmitted  to  the  sacrum  from  above  and  in  front,  as  in  the  ky- 
photic pelvis,  rather  than  from  behind  and  above,  as  is  the  case  in  a 
natural  position,  and  the  pelvis  would  neither  acquire  its  normal  ante- 
rior curvature  nor  its  posterior  inclination.  The  same  theory  explains 
the  failure  of  the  sacrum  to  exert  its  usual  wedge-like  action  in  sepa- 
rating the  ossa  innominata,  and  accounts  for  the  consequent  approxi- 
mation of  the  tubera  and  spines  of  the  opposite  ischia. 

Diagnosis. — In  cases  of  slight  deformity  the  diagnosis  is  difficult. 
In  well-marked  cases  the  approximation  of  the  ischial  tuberosities, 
the  slight  divergence  of  the  pubic  rami,  and  the  acute  sub-pubic 
angle  are  readily  appreciated.  Arrest  of  the  head  after  it  has  already 
descended  into  the  true  pelvis  will  often  be  the  first  circumstance 
serving  to  direct  the  attention  to  the  possible  existence  of  funnel- 
shaped  pelvis.  Pelvic  mensuration,  with  particular  reference  to  the 
distance  between  the  spines  of  the  ischia  and  to  the  width  of  the  sa- 
crum, will  establish  the  diagnosis. 

Prognosis. — In  the  slighter  grades  of  funnel-shaped  pelves,  the 
prognosis  is  not  grave.  If  the  deformity  be  marked,  however,  the 
child's  life  must  almost  invariably  be  sacrificed  ;  and  gangrene  of  the 
maternal  soft  parts,  with  resulting  cicatrices  and  fistulae,  or  even  with 
caries  of  the  pubic  bones,  may  be  the  consequence  of  the  excessive 
pressure  to  which  these  tissues  are  liable.  In  a  case  reported  by 
Scharlau  the  lesions  already  mentioned  were  accompanied  by  perfora- 
tion of  tlje  fundus  uteri  from  gangrene,  and  by  rupture  of  the  right 
sacro-iliac  artery.  | 

The  treatment  consists  in  the  induction  of  premature  labor,  or,  at 
term,  in  a  cautious  attempt  to  deliver  with  forceps.  Should  moderate 
tractions  fail  to  advance  the  head,  perforation  and  extraction  with  the 
cranioclast  should  be  resorted  to. 

*  Spiec.klderg,  "  Lehrbuch,"  p.  4*72.  f  Sciiroedkr,  "  Lchrbuch,"  p.  582. 

X  Scharlau,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxvii,  1866,  p.  1. 


RARE  FORMS  OF  PELVIC  DISTORTION. 


495 


VIL  Pelves  defokmed  by  Osteomalacia. 

Osteomalacia  is  almost  confined  to  females,  and  appears,  ordina- 
rily, in  the  puerperal  state.  It  usually  attacks  fully-developed  bones, 
but  may,  rarely,  affect  them  during  their  period  of  growth.  It  is  gen- 
erally observed  in  multiparae,  although  primiparae  are  in  exceptional 
cases  its  victims.  Each  succeeding  pregnancy  is  usually  attended  by 
a  progressive  development  of  the  disease,  which  may,  however,  become 
non-progressive,  or  even  be  completely  and  permanently  arrested.* 
In  a  case  of  this  kind  the  bone  is 
restored  to  its  normal  histological 
state,  although  its  deformity  re- 
mains. Osteomalacia  may  involve 
the  entire  osseous  system,  or  be  con- 
fined to  individual  bones.  In  the 
latter  case  the  long  bones  and  the 
vertebrae  are  most  frequently  dis- 
eased, f  In  puerperal  osteomalacia 
the  pelvis  and  the  vertebrae  are  pre- 
dominantly and  often  exclusively 
affected.  The  disease  is  regarded 
as  an  osteomyelitis,  which,  begin- 
ning in  the  center  of  bones,  advances 
toward  their  periphery.  The  essen- 
tial pathological  process  consists  in  Fio.  2U.-Osteomalacia.  (Specimen  from 
\  P  Wood's  Museum.) 

the  absorption  of  calcareous  matter, 

through  the  Haversian  canals,  and  in  the  substitution  of  hypertrophic 
medullary  tissue  for  the  softened  osseous  structures.];  The  natural 
result  of  the  changes  is  great  friability  or  pliability  of  the  bones,  ac- 
cording to  the  stage  reached  by  the  disease,  and  their  consequent 
distortion  by  compression  or  traction.  The  bones  are  of  very  light 
weight.  Their  transverse  section  reveals  a  porous,  diploe-like  struct- 
ure. Their  outer,  hard  lamella  is  exceedingly  thin,  or  entirely  ab- 
sent. The  bones  are  of  a  wax-like  softness,  being  readily  cut  and 
molded.*  The  term  rubber  or  elastic  pelvis  has  been  applied  to 
those  pelves  whose  bones  have  reached  this  stage  of  degeneration. 
In  the  most  advanced  cases  the  osseous  tissue  is  represented  merely 
by  membranous  sacs  of  periosteum  inclosing  medullary  tissue  and 
fat. 

Morbid  Anatomy. — The  osteomalacic  pelvis  presents  the  following 
pathological  anatomical  features  :  The  sacral  lateral  masses  are  very 

*  WiNCKEL,  "Monatsschr.  f.  Geburtsk.,"  Bd.  xxiii,  1864,  p.  321. 
+  LiTziiANN,  "Die  Formen  dcs  Bcckens,"  Berlin,  1861. 

X  Sjiiiioeder,  "Lehrbuch,''  p.  615. 

*  ScHiECK,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxvii,  1866,  p.  178. 


496 


THE  PATHOLOGY  OF  LABOR. 


narrow,  and  the  entire  bone,  which  is  displaced  downward  between  the 
ilia,  is  sharply  curved.  The  promontory  is,  accordingly,  deeply  de- 
pressed and  approximated  to  the  symphysis  as  well  as  to  the  apex  of 
the  sacrum,  which  is  itself  displaced  forward  and  curved  upward. 
The  promontory  and  the  apex  of  the  sacrum  may,  in  marked  cases, 
almost  touch  each  other.  The  ilia  are  placed  almost  vertically. 
Their  crests  are  elongated  and  sharply  curved.  The  anterior  superior 
spinous  processes  are  approximated.  The  posterior  superior  spinous 
processes  are  in  the  same  plane  with  the  posterior  surface  of  the  last 
lumbar  spinous  process.  The  iliac  fossa  is  divided,  near  its  middle, 
by  a  vertical  furrow  which  may  be  bifurcated  at  its  lower  end.  A 
prominence  corresponding  to  either  acetabulum  encroaches  more  or 
less  upon  the  pelvic  canal.  In  grave  cases  these  prominences  may 
even  come  in  contact  with  the  promontory.*  The  pubic  bones  are  in 
close  apposition,  and  the  pelvic  inlet  is  consequently  pointed  anteri- 
orly, while  the  symphysis  is  prominent  and  sharply  angular.  The 
ascending  rami  of  the  ischia  and  the  descending  rami  of  the  pubes 
are  approximated,  and  the  sub-pubic  arch  is  partly  or  completely  abol- 
ished. The  tuberosities  of  the  ischia  are  approximated.  The  deform- 
ities described  may  be  asymmetrical.  The  pelvic  canal  is  greatly 
narrowed,  the  outlet  usually  suffering  more  distortion  than  the  inlet. 
The  pelvic  inlet  and  canal  are  of  triangular  form,  and  assume,  in  the 
highest  grades  of  the  disease,  the  shape  of  the  letter  Y.  The  trans- 
verse diameter  is  always  contracted,  and  its  shortening  is  more  marked 
as  the  outlet  is  approached.  The  approximation  of  the  ischial  tuber- 
osities and  of  the  pubic  bones,  together  with  the  anterior  displace- 
ment of  the  apex  of  the  sacrum,  sometimes  almost  obliterates  the 
outlet. 

Etiology. — The  etiology  of  this  pelvic  deformity  may  be  divided 
into — 1.  That  of  the  original  disease  ;  and,  2.  That  of  the  result- 
ing distortions.  1.  The  causes  of  osteomalacia  are  obscure.  Cold 
and  damp  dwellings,  insufficient  air  and  light,  inadequate  aliment, 
and  exposure,  are  cited  as  exciting  causes,!  but  it  seems  probable 
that  these  alone  are  insufficient  etiological  agencies  unless  some  un- 
determined predisposing  cause  be  already  in  operation.  The  disease 
is  sometimes  observed  to  assume  an  endemic  form,  particularly  in 
countries  where  the  above-mentioned  exciting  causes  prevail,  as,  for 
instance,  in  the  Rhine  provinces  and  in  some  parts  of  Italy.  In  the 
United  States  it  is  only  observed  in  isolated  cases,  usually  in  persons  of 
foreign  birth.  2.  The  immediate  causes  of  the  distortions  are  found 
(a)  in  the  altered  structure  of  the  bones,  and  (b)  in 'the  various  forces 
acting  mechanically  upon  them,  (a)  The  lime-salts,  which  impart 
stability  to  normal  bones,  are  greatly  diminished.    Although  it  is  not 

*  Spiegelbero,  "  Lehrbuch,"  p.  488. 

f  Hennig,  "  Arch.  f.  Gynaek.,"  Bd.  v,  1873,  p.  519  et  seq. 


RARE  FORMS  OF  PELVIC  DISTORTION. 


497 


definitely  known  by  what  emunctories  they  are  removed,  it  is  probable 
that  they  are  chiefly  excreted  by  the  kidneys.  Gusserow  'states  that 
the  proportion  of  lime-salts  in  the  milk  of  women  suffering  from  osteo- 
malacia is  abnormally  large.  *  Pagenstecher  opposes  this  view,  f  (b) 
The  distortions  are  chiefly  produced,  when  once  softening  of  the  bones 
has  occurred,  by  the  muscular  traction  and  by  the  pressure  exerted 
upon  the  pelvic  walls.  This  pressure  will  vary  in  direction  and  inten- 
sity with  the  different  positions  assumed  by  the  patient.  If  the  dorsal 
decubitus  be  long  maintained,  the  sacrum  is  displaced  forward  and  the 
ilia  are  folded  upon  themselves,  so  that  a  vertical  furrow  traverses  the 
iliac  fossae.  In  the  erect  position  the  sacrum  is  forced  downward  and 
forward,  dragging  with  it  the  posterior  parts  of  the  ilia,  and  increas- 
ing the  bend  in  the  iliac  fossa.  The  same  effect  is  produced  by  the 
upward  and  backward  pressure  exerted  upon  the  acetabula  by  the 
femoral  heads.  In  the  lateral  position  the  ilia  are  forced  inward,  and 
the  transverse  pelvic  diameter  is  thus  diminished.  In  the  sitting  post- 
ure the  apex  of  the  sacrum  and  the  tubera  ischii  are  forced  upward.  The 
deviations  referred  to  above  result  from  excess  of  pressure  in  some  given 
direction,  or  from  unequal  progress  of  the  disease  in  the  various  bones. 

Diagnosis. — In  the  earlier  stages,  the  history  of  violent  pains  in  the 
pelvis  and  lower  extremities  will  direct  attention  to  the  existence  of 
osteomalacia,  and  careful  mensuration  will  reveal  beginning  distortion. 
Pelvimetry  is  most  satisfactorily  performed  during  anaesthesia,  which 
permits  the  introduction  of  the  entire  hand  within  the  pelvis.  If  the 
disease  be  more  advanced  the  diagnosis  will  be  based  upon  the  above- 
mentioned  morbid  anatomical  features,  chief  among  which  are  the 
prominent  pointed  symphysis,  the  parallel  pubic  rami,  the  approxima- 
tion of  the  tubera  ischii,  the  accessibility  of  the  promontory  to  palpa- 
tion, the  curvature  of  the  sacrum,  and  the  folding  of  the  ilia.  Spie- 
gelberg  insists  on  the  value  of  the  pliability  of  the  pelvic  bones  as  an 
aid  to  diagnosis.  J  The  pliability,  although  slight  during  pregnancy, 
is  more  marked  in  labor.  Its  first  sign  is  great  sensitiveness  to  press- 
ure over  the  symphysis.*  Its  grade  can  be  determined  by  the  method 
recommended  for  pelvic  measurements. 

Prognosis. — The  prognosis  for  the  mother  is  very  bad.  The  ma- 
jority of  patients  succumb  to  the  effects  of  pressure  in  labor,  to  the 
results  of  operative  interference,  or  to  the  exhaustion  attending  the 
almost  invariably  progressive  disease.  Amelioration  of  the  symptoms 
and  signs  sometimes  occurs  when  conception  does  not  recur.  In  very 
exceptional  cases  not  only  may  the  pathological  process  be  arrested 
but  the  normal  histological  character  of  the  bone  restored,    (a)  Even 

*  GussEROw,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xx,  1862,  p.  19. 
\  Pagenstecher,  "Monatsschr.  f,  Geburtsk.,  xix,  1862,  p.  128. 
X  Spiegelberg,  "  Lchrbuch,"  p.  489. 

*  WiNCKEL,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxiii,  1864,  p.  81. 
82 


498 


THE  PATHOLOGY  OF  LABOR. 


in  such  cases,  however,  the  pelvic  deformity  remains  unaltered,  and 
would  sadly  cloud  the  prognosis  if  conception  should  recur.  The 
prognosis  for  the  child  is  more  favorable.  In  the  beginning  of  the 
disease,  and  in  cases  of  pliable  pelvis,  the  child  maybe  born  uninjured.* 
In  more  advanced  cases  a  fair  prospect  of  preserving  its  life  is  afforded 
by  a  resort  to  the  Caesarean  section. 

The  treatment  will  depend  upon  the  results  of  a  careful  exploration 
of  the  pelvic  space.  This  should  determine,  first,  whether  it  is  possi- 
ble to  extract  a  living  child  through  the  natural  passages  ;  or,  second, 
where  that  is  out  of  the  question,  whether  it  is  possible  to  deliver  after 
craniotomy.  In  estimating  the  chances  it  will  be  necessary  to  take 
into  consideration  the  pliability  of  the  pelvis,  it  having  been  found 
possible  in  many  cases  of  advanced  softening  to  open  up  the  pelvic 
canal  with  the  hand  and  deliver  by  version.  Lazzati  and  Casati,  in 
Milan,  found  it  was  only  necessary  to  perform  Caesarean  section  twice 
in  sixty-two  cases.  Litzmann  in  1857  reported  forty .  Caesarean  sec-  . 
tions  in  eighty-five  cases  ;  fifteen  years  later  Hugenberger  reported  but  : 
four  Caesarean  sections  in  twenty-five  cases  (Spiegel berg).  : 

Pseudo-Osteomalacia. — It  is  possible  for  a  rachitic  pelvis,  in  which 
the  rachitic  changes  are  excessive,  to  present  a  shape  similar  to  that  in  , 
osteomalacia.    This  form  is,  however,  distinguishable  from  the  latter  ' 

through  the  hardness  of  the  bones,  their 
smaller  size,  the  greater  distance  be-  ' 
tween  the  anterior  superior  spinous  ; 
processes,  and  the  traces  of  rickets  in  j 
other  parts  of  the  skeleton.    (P.  445.)  | 

VIII.  Pelves  deegkmed  by  Exosto- 
sis, OK  BY  Osseous  Tumors. 

Fractures  of  the  pelvic  bones  may 
be  the  source  of  pelvic  deformity,  either 
by  producing  permanent  displacement 
of  the  bones,  or  by  leading  to  such  ex- 
tensive deposits  of  callus  as  to  obstruct 
the  parturient  canal. 

Multiple  exostoses  of  the  pelvic 
bones  are  of  comparatively  frequent 
occurrence,  and  are  usually  attended 
by  multiple  exostoses  of  the  entire  os- 
seous framework,  f  The  pelves  in  which  they  are  found  are,  as 
a  rule,  either  of  the  oblique-ovate  or  of  the  rachitic  variety,  and  the 

*  Kezmarszky,  "  Arch.  f.  Gynaek.,"  Bd.  iv,  1872,  p.  537 ;  Fasbender  and  Pcllen, 
"  Monatsschr.  f.  Geburtsk.,"  Bd.  xxxiii,  1869,  p.  177  ;  Breslau,  Ibid.,  Bd.  xx,  1862,  p. 
355  ;  ScHiECK,  Ibid.,  Bd.  xxvii,  1866,  p.  178;  Winckel,  Ibid.,  Bd.  xxiii,  1864,  p.  81. 

f  Leopold," Arch.  f.Gynack.,"  Bd.  iv.,  1872,  p.  336 ;  Kormann,  Ihid.,  Bd.  vi.,  1874,  p.  472. 


Fig.  215. — Osseous  tumors  filling  pelvic 
cavity.  (Naegcle.) 


RARE  FORMS  OF  PELVIC  DISTORTION. 


499 


combination  of  these  deformities  is  naturally  a  serious  one,  since  the 
maternal  soft  parts  are  liable  to  contusion  and  perforation  at  many 
points  during  parturition.  The  ilio-pectineal  eminence  is  sometimes 
so  unusually  prominent  and  sharp  as  to  offer  an  obstacle  to  parturition. 
The  same  is  true  of  the  pubic  crest  and  spine.  Osteofibromata,  sarco- 
mata, enchondromata,  and  carcinomata  connected  with  the  pelvic 
bones  constitute  tumors  of  rare  occurrence.  They  usually  spring 
from  the  sacrum  or  from  the  symphysis,*  and  are  of  various  dimen- 
sions. Some  of  them  almost  completely  occlude  the  parturient  canal, 
and  may  constitute  formidable  obstructions  to  delivery. 

In  this  connection  may  be  mentioned,  as  of  rare  occurrence,  anchy- 
losis of  the  coccyx,  a  condition  which  materially  shortens  the  antero- 
posterior diameter  of  the  outlet. 

IX.  Absence  of  the  Symphysis. 

In  this  variety  of  deformed  pelvis  the  symphysis  is  congenitally 
absent,  and  is  replaced  either  by  strong  fibrous  bands  extending  be- 
tween the  opposing  surfaces  of  the  pubic  bones,  or  by  the  muscles  and 
connective  tissue  of  the  perinseum.  It  is,  accordingly,  designated  by 
Litzmann  the  split  pelvis,  f 

Morbid  Anatomy. — It  is  usually  attended  by  ectopia  vesicae  and  by 
hiatus  of  the  abdominal  wall  in  the  linea  alba.  In  rare  cases  an  abdom- 
inal hiatus  exists  without  a  corresponding  opening  in  the  bladder.  If 
the  split  be  located  immediately  below  the  symphysis,  the  urethra  is 
involved  rather  than  the  bladder,  and  is  sometimes  so  defective  that 
cystocele  may  occur  through  the  abnormal  opening  in  its  anterior  wall.  X 
Both  the  external  and  internal  organs  of  generation  are  imperfectly 
developed.  If  the  anterior  wall  of  the  urethral  canal  be  absent,  the  mu- 
cous membrane  of  the  fundus  vesicae  is  directly  continuous  with  that  of 
the  vaginal  orifice.  In  other  cases  the  bladder  is  only  separated  from 
the  vulva  by  a  narrow  bridge.  The  vulva  and  anus  are  often  situated 
more  anteriorly  than  normal,  and  the  perinaeum  is  thus  diminished  in 
thickness.  The  clitoris  is  bifurcated  or  absent,  the  nymphae  are  imper- 
fectly developed,  and  the  defective  labia  majora  widely  separated.  The 
vagina  may  be  imperforate  or  partially  occluded  by  a  transverse  septum. 
The  uterus  may  be  double  and  the  ovaries  rudimentary.*  In  a  case 
reported  by  Winkler,  separation  of  the  pubic  bones  had  occurred  at 
the  symphysis,  as  the  result  of  an  accident  in  early  life,  and  they  were 
only  connected  by  bands  of  fibrous  tissue. ||  The  sacrum  of  a  split  pelvis 

*  Harris,  "Am.  Jour,  of  Obstet.,"  vol.  iv.,  18'72,  pp.  633,  645;  Braun,  "Monatsschr. 
f.  Geburtsk.,''  Bd.  xxi,  1863,  p.  311. 

f  Litzmann,  *'  Die  Formen  des  Beckens,"  Berlin,  1861. 

X  Kleinwachter,  "  Monatsschr.  f.  Geburtsk,,"  Bd.  xxxiv,  1869,  pp.  81  et  seq. 

*  Litzmann,  "Arch.  f.  Gynaek.,"  Bd.  iv,  1872,  p.  272. 
I  Winkler,  "Arch.  f.  Gynack.,"  Bd.  i,  1870,  p.  346. 


500 


THE  PATHOLOGY  OF  LABOR. 


is  displaced  forward  between  the  ilia,  its  vertical  and  transverse  curva- 
ture diminished,  and  its  length  increased.  The  iliac  fossae  are  widely 
separated.  The  entire  pelvis  is  greatly  flattened  antero-posteriorly, 
and  strongly  resembles  the  rachitic  pelvis. 

Etiology. — The  cause  of  the  existing  deformity  is  found  in  the 
increased  pressure  to  which  the  lateral  pelvic  walls  are  subjected  ow- 
ing to  the  absence  of  the  symphysis.  The  natural  resistance  to  the 
separation  of  the  lateral  pelvic  parietes,  offered  by  the  normal  symphy- 
sis, being  wanting,  the  weight  of  the  superimposed  trunk  naturally 
forces  them  apart  posteriorly,  while  the  pressure  of  the  femora  bends 
them  inward  anteriorly.  In  some  instances  anchylosis  of  the  sacro- 
iliac joints  occurs,  as  a  consequence  of  an  arthritis  resulting  from  the 
increased  pressure  thrown  upon  them  by  the  lateral  displacement  of 
the  ossa  innominata.*  In  other  cases  sacro-iliac  synostosis  is  not  pres- 
ent, but  the  firmness  of  the  pelvis  is,  nevertheless,  such  as  to  admit  of 
unimpeded  locomotion. 


CHAPTER  XXYIII. 

ABNOBMALITIES  OF  THE  SEXUAL  OEGAW. 

Atresia  of  the  genital  canal. — Vulvar  atresia. — Vaginal  atresia. — Cystocele. — Rectocele. 
— Retention  of  urine. — Impacted  calculi. — Vaginal  hernias. — Cystic  degeneration  of 
the  vaginal  wall. — Vaginismus. — Echinococci. — Uterine  atresia.— Cong] utinatio  ori- 
ficii  externi. — Cicatricial  atresia. — Rigidity. — Thrombus  of  the  cervix,  —  Symptoms 
of  atresia. — Note  on  treatment. — Tumors. — Fibroids. — Cancer. — Ovarian  tumors. 

Atresia  of  the  Genital  Canal.  Obstruction  of  the  Gen- 
erative Passages  by  Morbid  Processes  in  Neighboring 
Tissues. 

I.  Vulvar  Atresia. — The  term  atresia,  as  here  employed,  implies 
either  partial  or  complete  obstruction  of  the  genital  canal. 

Atresia  of  the  hymen,  usually  denominated  imperforate  hymen,  is 
of  more  frequent  occurrence  than  any  other  variety  of  vulvar  steno- 
sis, t  Unless  unusually  thick  and  rigid,  however,  the  imperforate  hy- 
men offers  only  a  trifling  obstruction  to  delivery.  Its  chief  importance 
is  owing  to  the  fact  that  it  leads,  in  the  unimpregnated  state,  to  reten- 
tion and  accumulation  of  the  menstrual  fluid,  which  may  occasion 
serious  inflammatory,  septic,  or  reflex  nervous  phenomena.  Adhesions 
of  the  labia  majora  and  minora  constitute  other  forms  of  incomplete 
vulvar  atresia.  Their  causes  are  often  ulcerative  processes  resulting 
from  injuries,  or  developed  during  the  course  of  variola  and  other  con- 

*  Freund,  "  Arch,  f.  Gynack.,"  Bd.  iii,  1872,  pp.  398,  406. 

f  Jenks,  "  Atresia  of  the  Generative  Passages  of  Women,"  "  Chicago  Med,  Jour,  and 
Examiner,"  September,  1880,  p.  4. 


ABNORMALITIES  OF  THE  SEXUAL  ORGANS. 


501 


stitutional  diseases.  Under  these  circumstances  they  may  consist  of 
unyielding  cicatricial  tissue,  which  either  ruptures  in  labor,  or,  forcing 
the  head  backward,  leads  indirectly  to  the  exertion  of  injurious  press- 
ure upon  the  recto-vaginal  septum  or  upon  the  perinaeum.  If  the 
atresia  be  congenital,  and  not  the  result  of  cicatricial  changes,  it  will 
rarely  constitute  an  impediment  to  parturition.  When  the  entrance 
to  the  vagina  is  very  narrow,  without  exhibiting  any  pathological  con- 
dition, as  is  often  the  case  with  aged  primiparae,  it  may  be  extensively 
lacerated  in  labor.  A  rigid  perinaeum  is  also  well  known  to  constitute 
a  serious  impediment  to  the  normal  progress  of  parturition.  (Edema 
of  the  vulva,  usually  attendant  upon  albuminuria,  produces  atresia, 
and  the  oedematous  labia  and  perinaeum  may  become  gangrenous  from 
excessive  pressure  during  labor.  Vulvar  haematoma,  or  thrombus,  if 
formed,  as  it  rarely  is,  before  delivery,  likewise  obstructs  the  outlet  of 
the  parturient  canal.  A  similar  effect  is  produced  by  cancers  and 
polypi  of  the  vulva,  which  are,  however,  not  often  of  sufficient  size  to 
occasion  serious  difficulty. 

II.  Vaginal  Atresia. — This  variety  of  stenosis  of  the  generative 
passages  is  either  congenital  or  accidental,  complete  or  incomplete. 

(a)  The  congenital  form  may  be  either  incomplete,  in  which  case 
the  stenosis  sometimes  affects  the  entire  length  of  the  vagina,  and 
sometimes  forms  a  circumscribed  ring-like  stricture,*  or  it  may  be  com- 
plete. In  either  case  the  atresia  is  due  to  arrested  embryonic  develop- 
ment, which,  in  the  latter  instance,  must  have  originated  at  a  very  early 
period  of  fetal  life.  Congenital  narrowing  of  the  vagina  independent 
of  any  morbid  process  or  any  arrest  of  development  is  often  observed, 
but  is  of  trifling  consequence,  being  overcome  by  the  hypertrophy  and 
relaxation  accompanying  pregnancy,  and  by  the  natural  expulsive 
forces.  Absence  of  the  vaginal  canal  does  not  necessarily  imply  ab- 
sence or  imperfect  development  of  the  uterus.  Fallopian  tubes,  or 
ovaries. 

(b)  Accidental  vaginal  atresia  may  be  either  complete  or  partial, 
but  is  ordinarily  of  the  latter  form.  Both  varieties  result  from  the 
cicatrization  following  superficial  or  deep  ulceration  produced  by  con- 
stitutional diseases  or  by  local  injury.  The  diseases  during  the  course 
of  which  vaginal  ulceration  occurs  are  chiefly  diphtheria,  variola,  ty- 
phoid fever,  cholera  Asiatica,  and  syphilis.  The  mechanical  injuries 
productive  of  vaginal  stenosis  are  mainly  those  incident  to  protracted 
labors,  to  the  unskillful  employment  of  instruments,  or  to  the  improper 
performance  of  obstetrical  operations  ;  but  caustic  local  applications, 
pessaries,  excessive  coition,  or  any  local  irritant  of  sufficient  intensity 
to  produce  ulceration,  may  lead  to  the  same  result.  In  consequence 
of  impaired  vitality,  ulceration  and  stenosis  of  the  vagina  may  follow 
normal  labors  unattended  by  any  injurious  pressure.    Complete  acci- 

*  ScHROEDER,  "  Lehrbuch,"  6te  Aufl.,  p.  491. 


502 


THE  PATHOLOGY  OF  LABOR. 


dental  vaginal  atresias  are  produced,  as  a  rule,  by  grave  mechanical 
injuries,  but  may,  according  to  Spiegelberg,*  also  follow  the  acute  in- 
fectious diseases  enumerated  above,  although  the  ulcerations  attending 
the  latter  usually  lead  to  only  partial  stenosis. 

Mention  may  properly  be  made,  in  this  connection,  of  various  mor- 
bid conditions  involving  tissues  adjoining  the  vagina  and  resulting 
in  diminution  of  its  caliber. 

Simple  prolapse  of  the  anterior  vaginal  wall  sometimes  occurs, f 
and,  assuming  an  oedematous  condition  owing  to  the  obstruction  of  its 
circulation,  decidedly  constricts  the  parturient  canal.  Cystocele  fre- 
quently accompanies  the  prolapse  of  the  anterior  vaginal  wall.  If  the 
bladder  be  distended  with  urine,  the  cystocele  presents  a  tense,  fluctu- 
ating tumor  of  sufficient  size  to  completely  occlude  the  vagina.  The 
subjective  symptoms  of  this  condition  are  intense  pain  with  vesical 
tenesmus  and  dysuria.  In  some  cases  the  cystocele  is  retracted  by  the 
longitudinal  cervical  contractions,  or  it  may  be  forced  still  farther 
downward  by  the  advancing  foetus,  producing  obstructed  labor  and 
eve^  rupture  of  the  vesico-vaginal  septum. 

Prolapse  of  the  posterior  vaginal  wall  with  rectocele  produces 
vaginal  stenosis,  especially  if  the  rectum  be  filled  with  impacted  f  geces. 
This  condition  is  easily  recognized  by  the  characteristic  feeling  of  the 
fecal  mass,  which  admits  of  indentation  by  the  palpating  finger. 

Eetention  of  urine  becomes  oftentimes  a  grave  complication  of 
parturition,  in  that  the  distended  bladder,  by  displacing  the  uterine 
axis,  prevents  the  presenting  part  from  engaging  in  the  superior  strait. 
The  pressure  it  exerts  upon  the  uterus  also  interferes  with  the  efficient 
contraction  of  that  organ.  The  diagnosis  is  based  upon  the  presence 
of  a  tumor  near  the  uterus,  and  often  situated  laterally  from  it,  which 
disappears  as  the  urine  is  withdrawn  through  a  catheter.  The  intro- 
duction of  the  latter  is  often  extremely  difficult,  owing  to  the  com- 
pression of  the  urethra  and  the  retraction  of  the  meatus  urinarius 
within  the  vagina. 

Vesical  calculi,  if  of  any  considerable  magnitude,  seriously  obstruct 
the  caliber  of  the  vagina  by  becoming  impacted  in  the  base  of  the 
bladder,  the  urethra,  or  a  cystocele,  between  the  foetus  and  the  pelvic 
walls.  Under  these  circumstances  not  only  is  the  labor  obstructed, 
but  contusion  and  rupture  of  the  soft  parts,  resulting  in  vesico-vaginal 
fistula,  may  ensue. 

Impacted  calculi  have  sometimes  been  mistaken  for  exostoses,;]; 
but  attention  to  the  fact  that  they  are  immovable  during  the  pains 
and  movable  in  the  intervals,  together  with  the  use  of  the  vesical 
sound,  will  prevent  this  error. 

*  Spiegelberg,  *'  Lchrbuch,"  p.  505. 

f  Benicke,  "Ztschr.  f.  Gcburtsh.  u.  Gynaek.,"  Bd.  ii,  Heft  2,  1878,  p.  256. 
X  Schroeder,  "  Lehrbuch,"  6tc  Aufl.,  p.  500. 


ABNORMALITIES  OF  THE  SEXUAL  ORGANS. 


503 


Vaginal  hernia  consists  of  a  sac  formed  by  the  protrusion  of  the 
vaginal  wall,  lined  with  the  parietal  peritonaeum  and  containing  some 
of  the  abdominal  or  pelvic  viscera.  The  organs  usually  present  in  the 
sac  are  coils  of  the  small  and  large  intestine,  the  middle  portion  of  the 
rectum  with  its  elongated  meso-rectum,  parts  of  the  omentum,  por- 
tions of  the  urinary  bladder,  and  sometimes  blood,  with  various  prod- 
ucts of  peritoneal  inflammation.  The  location  of  the  hernia  is 
usually  in  the  posterior  vaginal  wall,  although  it  may  insinuate  itself 
between  the  uterus  and  the  bladder,  and,  descending,  produce  hernia 
of  the  labia  majora.  Perineal  hernias  are  formed  by  hernial  sacs 
which  pass  behind  the  ligamentum  latum  and  distend  the  perinaeum. 
The  intestinal  vaginal  hernia  is  the  most  important  variety,  inasmuch 
as  it  may  not  only  obstruct  labor,  but  may  itself  become  incarcerated 
or  strangulated,  thus  leading  to  symptoms  of  the  gravest  import. 
The  diagnosis,  which  can  be  rendered  very  probable  by  palpation  jper 
vaginam,  is  made  certain  by  a  rectal  examination. 

Vaginal  neoplasmata,  the  most  important  of  which  are  carcinomata 
and  fibromata,  are  rare  sources  of  vaginal  stenosis,  as  is  likewise 
thrombus  of  the  vagina.  Slight  obstruction  to  labor  may  result  from 
a  pathological  condition  of  the  vaginal  mucous  membrane  described 
by  Winckel,*  under  the  title  colpohyperplasia  cystica,  and  consisting  of 
the  development  in  the  mucous  membrane  of  numerous  small  and 
closely  aggregated  flattened  cysts.  The  cysts  are  believed  to  be  pro- 
duced by  the  distention  of  glandular  depressions  in  the  mucous 
membrane  with  mucus,  which,  according  to  Zweifel,t  eventually  pro- 
duces trimethylamine  gas  by  decomposition.  Others  consider  the  loca- 
tion of  the  gas  to  be  in  the  interstices  of  the  submucous  connective 
tissue.  X 

Vaginismus  is  rarely  a  cause  of  vaginal  stenosis  in  labor,  inas- 
much as  it  is  itself  a  cause  of  sterility.  It  has,  however,  been  found 
in  certain  instances  to  constitute  so  serious  an  obstacle  to  delivery  as 
to  necessitate  operative  interference.  In  double  vagina  the  septum  is 
sometimes  a  source  of  slight  vaginal  atresia. 

Intrapelvic  echinococci  constitute  a  rare  cause  of  vaginal  constric- 
tion. Wiener*  collected  seven  cases  of  pelvic  echinococci,  most  of 
which  occupied  the  loose  connective  tissue  between  the  vagina  and 
rectum.  The  leading  symptoms  due  to  their  presence  during  preg- 
nancy were  deep-seated  traction  in  the  pelvis,  severe  pain,  vesical 
tenesmus,  dysuria,  and  constipation.  Menstruation  was  undisturbed. 
The  tumors  were,  with  one  exception,  so  large  as  to  completely  ob- 
struct the  vaginal  canal,  rendering  operative  interference  necessary. 

*  WiNCKEL,  "Arch.  f.  Gynaek.,"  Bd.  il,  IS^l,  pp.  383,  406. 
f  ZwEiFEL,  "  Arch.  f.  Gynaek.,"  Bd.  ix,  p.  39. 

X  RuGE,  "  Arch.  f.  Gynaek.,"  Bd.  ix,  p.  465. 

*  Wiener,  "Arch.  f.  Gynaek.,  Bd.  vi,  p.  672. 


504 


THE  PATHOLOGY  OF  LABOR. 


In  one  instance  the  contraction,  from  cicatrization  of  the  hydatid  cyst 
following  puncture,  was  so  extensive  as  to  produce  vaginal  stenosis. 
Hydatids  may  be  mistaken  for  exostoses  of  the  bony  pelvis,  for  hsema- 
tocele,  malignant  intrapelvic  tumors,  pelvic  abscesses,  or  cellulitis. 
Their  differential  diagnosis  is  based  upon  the  presence  in  the  pelvis 
of  smooth,  tense  tumors  not  connected  with  the  uterus,  the  gradual 
development  of  the  tumors  without  constitutional  symptoms  of  any 
gravity,  the  presence  of  similar  tumors  in  other  organs,  particularly  in 
the  liver,  the  hydatid  thrill,  which  is  not  often  observed  on  account 
of  the  strong  pressure  to  which  the  cysts  are  exposed,  and,  finally, 
upon  the  examination  of  the  cystic  fluid. 

III.  Uterine  Atresia. — Uterine  atresias,  which  occur  less  frequently 
than  those  of  any  other  portion  of  the  genital  passages,*  may  be  con- 
genital or  accidental,  partial  or  complete.  Complete  atresias,  observed 
in  parturition,  have  become  so  during  pregnancy,  since  conception 
would  not  otherwise  have  occurred. 

Conglutinatio  orificii  externi,  or  adhesion  of  the  lips  of  the  os 
externum,  is  occasioned  by  the  superficial  union  of  the  opposing 
mucous  surfaces  through  the  medium  of  inspissated  epithelium  or 
of  new  connective  tissue  resulting  from  adhesive  inflammation  pro- 
duced by  vaginitis  or  cervical  endometritis.  Schroeder  f  regards  these 
atresias  as  always  incomplete,  and  seeks  their  origin  in  the  gradual 
induration  of  tissues  immediately  surrounding  the  os,  resulting  from 
old  inflammatory  processes.  According  to  his  views,  this  pathological 
condition  consists  of  deficient  expansibility  and  not  of  real  contraction 
of  the  OS  externum.  On  examination  no  marked  induration  of  the 
cervix  is  felt.  The  os  externum  is  hardly  perceptible  to  the  touch 
and  can  often  only  be  discovered  by  inspection.  If  the  examination 
be  made  during  the  first  stage  of  labor  the  internal  os  is  found  widely 
dilated,  while  the  os  externum  remains  persistently  contracted  and 
conveys  a  sensation  to  the  palpating  finger  akin  to  that  produced  by  a 
narrow  and  tense  rubber  band.  If  the  finger  or  an  appropriate  in- 
strument be  firmly  pressed  against  the  os  during  the  pain,  it  slowly 
yields  and  is  gradually  retracted  by  the  longitudinal  cervical  contrac- 
tions. In  default  of  such  simple  interference  the  cervical  tissues 
above  the  os  externum  become  enormously  distended,  and  may  finally 
be  ruptured.  ZweifelJ  refers  this  peculiarly  unequal  dilatation  of 
the  cervical  canal  to  an  abnormal  presentation  of  the  fetal  cranium 
and  to  a  consequent  local  expansion  of  the  anterior  uterine  wall.  The 
os  externum  having  been  simultaneously  forced  backward  into  the 
hollow  of  the  sacrum,  the  yielding  anterior  uterine  wall  then  forms  a 
diverticulum  which  contains  the  presenting  fetal  part,  and  no  dilating 
force  is  exerted  upon  the  external  os.    Benicke  *  was  unable  to  dis- 

*  Jenks,  op.  cit.,  p.  6.  f  Schroeder,  "  Lehibuch,"  6te  Aufl.,  p.  487. 

X  ZwEiEEL,    Arch.  f.  Gynack.,"  Bd.  v,  1873,  p.  149.  *  Benicke,  op.  cil.,  p.  252. 


ABNORMALITIES  OF  THE  SEXUAL  ORGANS. 


505 


cover,  in  his  cases,  the  posterior  deviation  of  the  os  which  is  assumed 
by  Zweifel  as  the  basis  of  his  hypothesis. 

Cicatricial  atresia  of  the  os  externum  is  rarer  than  the  adhesive 
stenosis  just  described.  It  is  usually  confined  to  the  lips  of  the  ex- 
ternal OS,  but  may  involve  the  cervical  canal  for  a  varying  distance. 
Its  most  frequent  causes  are  post-partum  ulceration,  inflammation, 
cauterization  of  the  cervix,  and  mechanical  irritation  applied  for  the 
purpose  of  producing  abortion.  The  diminution  of  the  uterine  dis- 
charges during  pregnancy  affords  a  favorable  opportunity  for  the  de- 
velopment of  the  stenosis  under  consideration.  If  cicatricial  atresia 
exist,  the  os  externum  remains  undilated  in  labor,  the  cervix  becomes 
immensely  distended,  and  may  even  rupture,  unless  the  os  be  dilated 
by  artificial  means.  The  diagnosis  rests  upon  the  discovery,  usually 
easily  made,  of  the  cicatrized  os  externum.  Should  the  latter  have 
retreated  into  the  hollow  of  the  sacrum,  the  diagnosis  may  only  be 
accomplished  with  difficulty,  or  the  expanded  cervical  tissues  be  mis- 
taken for  the  fetal  membranes.  This  error  is  avoided  by  the  discovery 
of  the  direct  continuity  of  the  vaginal  wall  and  the  supposed  mem- 
branes, and  by  inspection  through  a  proper  speculum. 

Abnormal  rigidity  of  the  os  externum  is  often  encountered  in  mul- 
tiparas as  the  result  of  genuine  cicatricial  processes  or  of  fibrous  hy- 
pertrophy. This  condition  is  especially  observed  in  connection  with 
prolapse  of  the  uterus.  A  similar  rigidity  in  aged  primiparae  is  due 
to  atrophic  degenerative  changes  in  the  cervical  tissues,  or  to  hyper- 
trophy of  the  portio  vaginalis.* 

Haemorrhages  occurring  into  the  hypertrophied  cervical  tissue  are 
distinguished  as  cervical  thrombi,  and  constitute  obstacles  to  delivery. 
The  retraction  and  dilatation  of  the  cervix  may,  further,  be  obstructed 
by  adhesions  in  the  lower  segment  of  the  uterus  between  the  decidua 
and  the  chorion. 

Acute  elongation  of  the  anterior  lip  of  the  os  externum,  in  conse- 
quence of  its  incarceration  between  the  fa3tus  and  the  bony  pelvis,  and 
of  the  resulting  oedema  of  its  tissues,  is  referred  to  by  Hirte  f  as  a  rare 
but  serious  obstacle  to  delivery. 

Parturition  is  sometimes  delayed  by  double  uterus.  The  ob- 
struction may  in  this  instance  be  produced  by  an  hypertrophied 
unimpregnated  horn  of  the  uterus.  J;  Again,  the  oblique  position  of 
the  impregnated  horn  may  produce  abnormal  presentations  *  or  ma- 
terially interfere  with  the  efficiency  of  the  pains. 

The  uterine  atresias  produced  by  carcinomata,  fibromata,  and  ova- 
rian tumors  are  considered  in  another  chapter. 

*  Benicke,  op.  dt.,  p.  240. 

f  Hirte,  "Arch.  f.  Gynaek.,"  Bd.  vii,  1875,  p.  552. 
X  MuLLER,  "Arch.  f.  Gynaek.,"  Bd.  v,  1873,  p.  132. 
«  ScHATZ,  "Arch.  f.  Gynaek.,"  Bd.  ii,  1871,  p.  297. 


506 


THE  PATHOLOGY  OF  LABOR. 


Symptoms  of  Atresias  of  the  Genital  Canal. — The  principal  symp- 
toms of  atresia  in  the  unimpregnated  state  relate  to  the  partial  or 
complete  retention  of  the  menstrual  fluids.  If  the  stenosis  be  com- 
plete the  uterus  is  enlarged  and  fluctuating,  while  severe  uterine  pains 
attend  each  monthly  period.*  The  Fallopian  tubes  are  dilated.  Some 
of  the  retained  and  decomposed  menstrual  fluid  may  be  forced  through 
the  tubes  into  the  peritoneal  cavity,  producing  serious  or  fatal  perito- 
nitis. The  mere  dilatation  of  the  uterus  may  become  so  excessive  as 
to  produce  peritonitis,  f  Septic  poisoning  is  sometimes  induced  by 
absorption  of  putrescent  materials  from  the  uterine  cavity.  A  symp- 
tom often  serving  to  attract  attention  to  the  existence  of  abnormal 
vaginal  contraction  is  inability  to  perform  the  sexual  act. 

The  most  prominent  symptom  of  atresia  during  parturition  con- 
sists, in  general  terms,  of  mechanical  obstruction  to  delivery,  which  is 
more  or  less  serious  in  proportion  to  the  degree  of  existing  stenosis. 
The  special  symptomatology  of  the  individual  pathological  conditions 
productive  of  atresia  has  been  considered  in  connection  with  their 
respective  anatomical  characters. 

Note. — Atresias  for  the  most  part  require  to  be  treated  each  by  itself,  according  to 
the  principles  of  surgical  art.  In  a  paper  by  Professor  I.  E.  Taylor,  in  the  fourth  volume 
of  the  "Transactions  of  the  American  Gynaecological  Society,"  entitled  "Atresia  of  the 
Vagina,  Congenital  or  Accidental,  in  the  Pregnant  or  Non-pregnant  Female,"  the  author 
relates  a  case  of  seemingly  complete  imperforation  of  the  vagina  complicating  labor,  where 
he  succeeded,  by  scraping  with  the  finger-nail  during  the  pains,  in  passing  the  index-finger 
through  the  intervening  membrane  to  the  child's  head,  and  eventually  in  securing  an 
opening  large  enough  for  the  birth  to  be  accomplished.  I  had  previously  reported  two 
similar  cases,  one  in  the  "  New  York  Medical  Jonrnal,"  and  one  to  the  Obstetrical  So- 
ciety.:}: The  first,  where  I  was  aided  by  Professor  Fordycc  Barker,  occurred  in  Bellevue 
Hospital,  and  the  second  in  private  practice.  In  both,  similar  success  followed  a  gradual 
dissection  of  the  vaginal  walls  with  the  finger.  In  such  cases  usually  a  depression,  or  a 
thinned  point  in  the  tissues,  indicates  the  direction  to  be  followed.  C.  Braun  states, 
however,  that  be  has  seen  three  cases  where  vesico-vaginal  fistulae  were  produced  by  this 
tunneling  process,  an  admonition  to  extreme  caution  in  its  performance.*  For  stenoses 
of  the  vagina,  dilatation  should  be  employed,  either  by  means  of  compressed  sponges,  the 
tampon  of  slippery-elm  (Skene),  or  the  water-bag.  When  dilatation  is  already  well  ad- 
vanced, incisions  may  be  used  to  aid  in  completing  the  process. 

Uterine  Tumors  complicating  Pregnancy,  Parturition,  and 
THE  Puerperal  State. 

I.  Uterine  Myomata. — 1.  In  pregnancy.  Because  of  the  disposi- 
tion of  uterine  myomata  to  produce  sterility,  they  naturally  constitute 
comparatively  infrequent  complications  of  pregnancy.    They  are  sub- 

*  DoHRN,  "Arch.  f.  Gynack.,"  Bd.  x,  1876,  p.  544;  I.  E.  Taylor,  "Atresia  of  the 
Vagina,"  "Trans,  of  the  Am.  GynjBC.  Soc,"  vol.  ix,  1880,  pp.  9,  12. 

f  I.  E.  Taylor,  loc.  cit.,  p.  16. 

X  "  Trans,  of  the  New  York  Obstet.  Soc,"  vol.  i,  p.  44. 

*  Braun  von  Fernwald,  "  Lehrbuch  der  gcsammt.  Gynaek.,"  p.  273. 


ABNORMALITIES  OF  THE  SEXUAL  ORGANS. 


607 


divided,  according  to  their  location,  into  subperitoneal,  interstitial, 
and  submucous  myomata.  The  presence  of  either  variety  diminishes 
the  probability  of  conception,  but  none  absolutely  precludes  the  possi- 
bility of  its  occurrence. 

Subperitoneal  myomata  prevent  conception  and  interrupt  utero- 
gestation  only  when  they  attain  large  dimensions,  and  their  preju- 
dicial influence  is  then  usually  referable  to  the  uterine  retroversions 
or  retroflexions  which  they  induce.  Interstitial  myomata  are  more 
likely  than  the  preceding  variety  to  occasion  abortion  or  premature 
delivery,  either  by  producing  uterine  flexions,*  or  by  acting  as  the 
exciting  cause  of  haemorrhages,  which  are  more  severe  when  the  pla- 
centa is  located  over  the  site  of  the  tumor.  This  statement  applies 
particularly  to  post-partum  haemorrhages,  inasmuch  as  the  muscular 
atrophy  induced  by  the  myoma  prevents  the  ready  and  complete  clo- 
sure of  the  uterine  sinuses. 

Submucous  myomata  rarely  permit  of  conception,  which,  in  the 
event  of  its  occurrence,  is  almost  uniformly  followed  by  abortion,  due 
usually  to  metrorrhagia.  \  In  rare  cases,  however,  pregnancy  progress- 
es to  its  normal  termination.  Myomata  ordinarily  participate  in  the 
uterine  hypertrophy  of  pregnancy,  becoming  at  the  same  time  softer 
and  more  succulent.  J  This  change  in  consistence,  which  is  referred 
to  increased  vascularity  and  to  serous  infiltration,  is  attended  by  dila- 
tation of  the  lymphatics,  which  may  lead  to  the  formation  of  cysts. 
The  softened  tumor  readily  undergoes  changes  of  form  under  the  in- 
fluence of  increasing  intrapelvic  pressure  and  of  uterine  traction.  It 
may  become  so  flattened  that  it  ceases  to  be  recognizable  as  a  tumor, 
but  regains  its  earlier  shape  after  delivery. 

The  diagnosis  of  uterine  myomata,  particularly  of  the  interstitial 
and  submucous  varieties,  is  often  attended  during  pregnancy  by  diffi- 
culty, inasmuch  as  their  symptoms  and  signs  are  obscured  by  those  of 
pregnancy.  On  the  other  hand,  the  existence  of  myomata  may  pre- 
vent the  recognition  of  pregnancy.  Fibrous  tumors  may  be  mistaken 
for  fetal  organs  or  for  intrauterine  cystic  tumors.  The  latter  error 
would  be  particularly  unfortunate  if  it  should  lead  to  puncture  of  the 
myoma  and  be  followed  by  metrorrhagia. 

2.  In  Parturition  and  the  Puerperal  State. — Uterine  polypi  act  as 
impediments  to  delivery  only  when  they  are  situated  beside  or  in  front 
of  the  advancing  child,  and  are  possessed  of  considerable  size  and  con- 
sistence. If  the  tumor  be  small,  movable,  and  yielding,  it  may  occa- 
sion only  trifling  obstruction  to  parturition  and  may  even  be  expelled 
by  the  advancing  foetus,  after  rupture  of  its  pedicle. 

Interstitial  myomata,  when  corporeal,  constitute  impediments  to 

*  PoNFiCK,  "  Beitr.  z.  Geburtsh.  u.  Gynaek.,"  Bd.  ii,  18*73,  p.  92. 

f  Thomas,  "  Am.  Jour,  of  Obstet.,"  vol.  viii,  p.  606. 

X  Spiegelberg,  "Arch.  f.  Gynaek  ,"  Bd.  v,  1873,  p.  110. 


508 


THE  PATHOLOGY  OF  LABOR 


delivery  only  when  located  in  the  lower  segments  of  the  uterus.  Even 
when  thus  situated,  they  often  spontaneously  recede  from  the  pelvic 
cavity  under  the  influence  of  the  longitudinal  uterine  contractions. 
By  exerting  traction  on  the  uterine  parietes  they  aggravate  the  sever- 
ity of  the  pains,  and,  according  to  Spiegelberg,*  sometimes  produce 
rupture  of  the  uterine  wall,  in  which  their  growth  has  already  deter- 
mined atrophic  degeneration.  By  interfering  with  symmetrical  uter- 
ine contraction,  interstitial  myomata  render  the  pains  irregular  and 
inefficient,  besides  predisposing  to  ante-  and  particularly  to  post-par- 
tum  haemorrhage.  By  altering  the  form  of  the  uterine  cavity  and 
preventing  the  engagement  of  the  head  in  the  superior  strait,  this 
variety  of  myoma  frequently  produces  abnormal  positions  and  presenta- 
tions, f  In  a  case  of  my  own  eclampsia  resulted,  apparently  from  the 
same  set  of  causes  as  those  which  obtain  in  multiple  pregnancy.  They 
also  predispose  to  the  development  of  retroflexions  in  the  puerperal 
state.  When  interstitial  myomata  are  developed  in  the  cervical  tissues 
they  almost  invariably  offer  a  mechanical  impediment  to  delivery,  and 
are  rarely  capable  of  being  displaced  above  the  superior  strait.  If,  how- 
ever, they  have  become  intra  vaginal  and  their  base  be  not  too  extensive, 
they  are  often  readily  amenable  to  appropriate  surgical  interference. 
In  default  of  the  latter,  fatal  compression  may  be  exerted  upon  the 
fetal  cranium,  or  the  vesico-vaginal  septum  may  be  lacerated  during 
labor. 

Subserous  myomata  are  ordinarily  developed  in  the  posterior  uter- 
ine wall.  If  connected  with  the  body  of  the  uterus  and  located  above 
the  retro-uterine  reflexion  of  the  peritonaeum,  they  may  be  spontane- 
ously extruded  from  the  pelvic  into  the  peritoneal  cavity.  They 
originate,  however,  most  frequently  in  the  cervical  tissues,  and,  ex- 
tending downward,  become  retro-vaginal,  more  or  less  completely  oc- 
cupy the  pelvic  cavity,  and  offer,  provided  their  size  be  at  all  con- 
siderable, an  insurmountable  obstacle  to  parturition.  This  variety  has 
been  designated  as  the  incarcerated  uterine  myoma.  J 

Treatment. — Interstitial  corporeal  myomata,  as  a  rule,  do  not  inter- 
fere with  the  expulsion  of  the  child.  Dr.  A.  Kessler  has  reported  a 
case  which  I  saw  with  him  in  consultation,  where,  after  the  expulsion 
of  a  four  months'  foetus,  it  was  found  impossible  to  reach  the  placenta. 
The  latter  occupied  an  inaccessible  position  near  the  right  cornu,  far 
out  of  reach  of  the  fingers,  while  the  convexity  of  the  tumor  was  such 
as  to  interfere  with  the  working  of  curettes.  The  patient  subsequently 
died  of  septicaemia.  Eemoval  of  the  entire  uterus  would,  perhaps, 
have  saved  her  life.  If  myomata  encroach  upon  or  occupy  the  pelvic 
cavity,  they  should  be  raised  above  the  brim  by  sustained  vaginal  and 
rectal  pressure. 

*  Spiegelberg,  "  Lehrbuch,"  p.  509.  f  Thomas,  loc.  ciL,  p.  608. 

X  Spiegelbeug,  "  Arch.  f.  Gynaek.,"  Bd.  v,  1873,  p.  100. 


ABNORMALITIES  OF  THE  SEXUAL  ORGANS. 


509 


The  most  serious  obstruction  to  the  birth  of  the  child  is  offered  by 
cervical  and  subserous  myomata  situated  behind  the  uterus,  and  nearly 
filling  the  pelvic  space.  In  such  cases  the  only  means  of  delivery  may 
be  by  the  Caesarean  section.  The  unfavorable  results  of  the  opera- 
tion, however,  when  complicated  by  the  presence  of  uterine  myomata, 
are  shown  by  Spiegel  berg's  report,  where  of  twenty-nine  mothers  but 
four  recovered.  A  successful  case  of  Caesarean  section,  made  neces- 
sary by  two  large  myomatous  tumors  of  the  uterus,  has  recently  been 
reported  by  Dr.  Moses  Baker,*  of  Stockwell,  Indiana.  Polypoid 
growths  should  be  pushed  back  into  the  uterus,  if  possible,  in  cases 
where  the  pedicle  is  out  of  reach.  Where,  however,  the  tumor  is 
shoved  down  in  advance  of  the  head,  and  the  pedicle  is  accessible,  it 
should  be  removed  with  the  ecraseur  or  with  scissors. 

Polypoid  elongation  of  the  anterior  lip,  where  replacement  is  im- 
possible, and  where  the  swelling  obstructs  labor,  may  call  for  the  de- 
struction of  the  child,  as  excision  is  likely  to  be  followed  by  dangerous 
haemorrhage. 

II.  Carcinoma  of  the  Cervix  Uteri. — 1.  In  Pregnancy.  Uterine 
cancer,  which  is  one  of  the  gravest  complications  of  pregnancy,  is,  if 
primary,  almost  without  exception  of  cervical  origin.  Conception 
often  occurs  in  the  earlier  stages  of  the  disease,  and,  since  it  is  only 
absolutely  prevented  by  a  carcinoma  which  completely  occludes  the 
cervical  canal,  it  occasionally  takes  place  even  in  the  later  stages  of 
the  neoplasm's  growth.  The  existence  of  pregnancy  usually  hastens 
the  development  of  the  cancer,  the  more  rapid  growth  of  which  is 
probably  referable  to  the  increased  vascularity  of  the  uterus  and  to 
the  correspondingly  augmented  activity  of  its  nutritive  processes.  In 
rare  instances  the  occurrence  of  pregnancy  seems  to  arrest  the  devel- 
opment of  the  local  and  general  symptoms  referable  to  the  cancerous 
growth,  t  In  the  majority  of  cases  the  neoplasm  does  not  interfere 
with  the  completion  of  normal  utero- gestation,  J;  although  abortion  or 
premature  delivery  is  a  frequent  result  of  its  development.  These 
issues  of  pregnancy  are  most  frequently  determined  by  cancerous  tu- 
mors whose  progress  has  invaded  the  higher,  supravaginal  portions 
of  the  cervix,  and  is  probably  occasioned  by  the  interference,  on 
the  part  of  the  neoplasm,  with  the  normal  process  of  uterine  growth 
and  expansion.  The  traction  exerted  by  the  enlarging  cervix  upon 
the  unyielding  tissues  of  the  tumor  may  also  produce  a  solution  of 
their  continuity,  and  give  rise  to  formidable  haemorrhage.  In  very 
exceptional  cases  uterine  carcinoma  seems  to  protract  the  period  of 
gestation  far  beyond  its  normal  limits,  in  which  case  the  foetus  dies 
and  undergoes  the  changes  usual  in  retention. 

*  "Am.  Jour,  of  Obstet.,"  1881,  vol.  xiv,  p.  596. 

f  Spiegelberg,  "Lehrbuch,"  p.  295. 

X  Benicke,  "Arch.  f.  Gynaek.,''  Bd.  x,  1876,  p.  405. 


510 


THE  PATHOLOGY  OF  LABOR. 


2.  In  Parturition  and  the  Puerperal  State. — If  the  cancer  be  con  - 
fined to  the  lower  margin  of  the  cervical  canal,  the  expansion  of  the 
latter  is  not  materially  interfered  with,  and  delivery  may  be  safely  and 
speedily  accomplished.  If,  however,  the  morbid  process  has  involved 
the  entire  portio  vaginalis,  or  has  even  extended  quite  to  the  os  inter- 
num, the  inelastic  tissue  of  the  cancerous  growth  has  replaced  the 
expansile  muscular  fibers,  and  an  opening  of  sufficient  caliber  for  the 
passage  of  the  foetus  can  only  be  produced  by  rupture  and  contusion 
of  the  degenerated  and  unyielding  cervix.  The  immediate  result  of 
such  a  laceration  is  violent  haemorrhage,  which  is,  however,  quite 
amenable  to  treatment.  The  consequence  of  the  excessive  pressure 
to  which  the  cervix  is  subjected  during  labor  is  necrosis  of  the  con- 
tused tissues,  which  is  frequently  followed  by  fatal  septicaemia. 

The  diagnosis  is  accomplished  by  the  same  means  which  are  em- 
ployed in  the  detection  of  cervical  cancer  in  the  unimpregnated  con- 
dition. 

The  prognosis  is  doubtful  for  both  mother  and  child.  The  latter 
is  imperiled  by  its  liability  to  premature  expulsion,  and  by  the  me- 
chanical obstruction  to  its  birth  produced  by  the  tumor.  The  moth- 
er's life  is  not  only  shortened  by  the  rapidity  of  the  cancerous  growth 
usually  induced  by  pregnancy,  but  is  jeopardized  by  her  increased  lia- 
bility to  abortion,  post-partum  haemorrhage,  and  puerperal  fever. 

Treatment. — During  pregnancy,  in  cases  where  the  disease  is  con- 
fined to  the  cervical  portion,  either  amputation  or  excision  should  be 
performed.  The  time  selected  for  operation  is  usually  the  fourth 
month.  Abortion  does  not  necessarily  follow.  In  advanced  stages, 
where  the  carcinomatous  process  has  invaded  the  contiguous  tissues, 
operative  interference  should  be  postponed  until  the  end  of  gestation. 
Just  in  proportion  as  the  outlook  for  the  mother  grows  question- 
able, the  interests  of  the  child  rise  in  importance.  An  extensive 
removal  of  diseased  tissue  during  pregnancy  exposes  the  mother  to  the 
immediate  dangers  of  premature  labor  and  subsequent  septicaemia, 
while  it  is  hardly  possible  to  do  the  work  so  effectively  as  to  procure  a 
free  outlet  for  the  child.  Upon  the  advent  of  labor,  if  the  child  be 
living,  the  Caesarean  section  certainly  holds  out  the  hope  of  saving  one 
life,  and  probably  does  not  greatly  increase  the  peril  to  which  the 
other  is  exposed.*  Dr.  Fordyce  Barker  states  that  he  has  met  with 
three  cases  of  spontaneous  delivery  where  the  cervix  was  carcinoma- 
tous, in  all  of  which  the  mother  survived  the  childbed  period.  Such 
good  fortune,  however,  is  necessarily  rare,  and  is  only  likely  to  result 
in  patients  whose  tissues  are  but  moderately  affected.    Frommel  \  re- 

*  Herman  ("Trans,  of  the  Obstet.  Soc.  of  London,"  vol.  xx,  p.  191)  reports  twelve 
Caesarean  operations,  with  four  recoveries. 

f  Frommel,  *'  Zur  operat.  Therapie  d.  Cervix-Careinoms  in  d.  Complication  mit  Gra- 
viditat,"  "Ztschr.  f.  Geburtsh.  und  Gynack.,"  Bd.  v,  p.  158. 


ABNORMALITIES  OF  THE  SEXFAL  ORGANS. 


5U 


ports  a  case  from  the  Berlin  Clinic,  where,  the  child  being  dead, 
Schroeder  broke  away  with  his  hands  large  masses  of  the  neoplasm, 
and  thus  provided  a  passage  of  sufficient  size  to  permit  the  extraction 
of  the  child  by  version.  The  patient  was  discharged  on  the  tenth  day, 
but  died  a  few  days  after. 

ni.  Ovarian  Tumors. — 1.  In  Pregnancy.  Ovarian  tumors,  par- 
ticularly those  of  the  cystic  variety,  are  quite  often  encountered  as 
complications  of  pregnancy.  They  usually  antedate  conception,  but 
may  make  their  appearance  during  pregnancy.  Utero-gestation  often 
favors  their  development  by  increasing  the  general  vascularity  of  the 
pelvic  viscera,  although  an  arrest  of  growth  and  an  actual  retrogres- 
sive metamorphosis  of  the  tumor  seem  to  be  the  occasional  effect  of 
intercurrent  conception.*  This  retrogressive  process  affects  only  cys- 
tic tumors,  and  may  result  from  the  uterine  pressure,  which  facilitates 
the  absorption  of  their  contents.  After  delivery  the  cysts  present  on 
palpation  a  relaxed  and  flabby  condition.  The  natural  tension  of  the 
tumor  is  soon  restored  by  the  secretion  of  additional  fluid,  except  in 
those  rare  cases  in  which  the  compression  of  the  gravid  uterus  seems 
to  initiate  a  permanent  process  of  retrogression  and  absorption. 

Wernich  f  advanced  the  opinion  that  the  assumption  by  benign 
ovarian  tumors  of  a  malignant  character  was  determined  by  the  occur- 
rence of  pregnancy,  and  Spiegelberg  J  regards  this  transition  as  posi- 
tively established.  The  ovarian  tumors  under  consideration  may  be 
bilateral.  If  they  be  of  moderate  dimensions,  they  may  not  interfere 
with  utero-gestation  or  delivery,  except  by  a  slight  aggravation  of  the 
usual  disturbances  attendant  upon  pregnancy.  An  ovarian  tumor  is, 
however,  liable  to  occasion  abortion  or  j^remature  delivery  if  it  be  con- 
fined by  adhesions  to  the  pelvic  cavity,  or  be  closely  connected  to  the 
uterus.  Under  these  circumstances  abortion  results  from  interference, 
on  the  part  of  the  new  growth,  with  the  natural  uterine  expansion,  or 
from  the  retroflexion  which  it  induces.  In  rare  instances  a  rotation 
of  the  cyst  upon  its  axis,  followed  by  strangulation  of  its  pedicle,  is 
observed.  This  deplorable  accident  leads  to  a  lethal  issue  by  shock, 
by  gangrene  of  the  cyst  and  consequent  septicaemia,  or  by  haemorrhage 
into  the  tumor  and  the  peritoneal  cavity,  followed  by  peritonitis.  The 
rationale  of  the  morbid  phenomena  referable  to  tumors  of  larger  size 
is  entirely  different.  These  tumors  do  not  often  occasion  abortion  or 
premature  delivery,  but  gravely  complicate  the  later  periods  of  preg- 
nancy by  means  of  the  pressure  which  they,  in  common  with  the  gravid 
uterus,  exert  upon  the  abdominal  and  thoracic  viscera.  Ascites  and 
dyspnoea  are  the  chief  results  of  the  augmented  intra-abdominal  ten- 
sion.   (Edema  of  the  lower  extremities  is  often  observed.    The  ova- 

*  Schroeder,  "  Lehrbuch,"  p.  399. 

f  Wernich,  "  Beitr.  z.  Geburtsh.  u.  Gyn,,"  Bd.  ii,  p.  143. 
X  Spiegelberg,  "  Lehrbuch,"  p.  297. 


512 


THE  PATHOLOGY  OF  LABOR. 


rian  cyst  sometimes  ruptures  and  produces  fatal  collapse,  peritonitis, 
or  septicaemia.  The  escaped  cystic  fluid  may,  however,  be  absorbed, 
and  pregnancy  reach  a  natural  termination. 

Diagnosis. — If  the  ovarian  tumor  be  of  small  size,  it  may  be  com_- 
pletely  masked  by  the  growing  uterus,  or  may  be  mistaken  for  a  por- 
tion of  the  latter.  If,  on  the  other  hand,  the  surface  of  the  tumor  be 
irregular  and  nodular,  the  uterus  may,  at  an  early  period  of  pregnancy, 
itself  be  regarded  as  a  part  of  the  cyst.  Palpation  and  auscultation 
will,  however,  usually  afford  satisfactory  diagnostic  points  of  depart- 
ure. Moreover,  the  absence  of  the  menses  in  patients  with  an  ovarian 
tumor,  and  an  unusually  rapid  increase  in  the  dimensions  of  the  abdo- 
men, should  awaken  the  suspicion  of  combined  pregnancy  and  ovarian 
tumor. 

2.  In  Parturition  and  the  Puerperal  State. — The  dangers  result- 
ing in  parturition  and  the  puerperal  state  from  ovarian  tumors  com- 
plicating pregnancy  are  twofold,  and  consist  («)  in  the  obstruction 
to  labor  which  they  occasion  and  {b)  in  the  results  of  the  morbid  pro- 
cesses determined  in  the  neoplasms  themselves  by  the  excessive  press- 
ure of  the  surrounding  tissues. 

{a)  If  the  ovarian  tumor  is  confined  within  the  true  pelvis  in 
such  a  way  as  to  render  its  spontaneous  or  manual  displacement  im- 
possible, it  may  offer  a  most  serious  impediment  to  the  expulsion  of 
the  foetus.  Dermoid  cysts  manifest  a  more  decided  tendency  to  con- 
tract adhesions  in  the  pelvis  than  other  ovarian  tumors,  and  afford 
on  this  account,  as  well  as  because  of  the  greater  consistence  of  their 
contents,  a  worse  prognosis  than  any  other  variety.*  Obstructed  labor 
more  frequently  results  from  the  presence  of  small  than  from  that  of 
large  ovarian  tumors,  since  the  latter  oftener  escape  into  the  abdomi- 
nal cavity  during  pregnancy,  and  are  unable  at  any  subsequent  period 
to  effect  an  entrance  into  the  true  pelvis. 

ifi)  Even  if  the  obstacle  offered  to  parturition  by  an  ovarian  tu- 
mor be  trivial,  the  changes  induced  in  its  own  substance  by  the  par- 
turient act  may  be  productive  of  very  serious  results.  The  pressure 
and  traction  exerted  upon  the  pedicle  of  the  cyst  are  often  so  severe 
as  to  produce  its  strangulation,  followed  by  necrosis  of  the  tumor, 
with  consequent  septic  poisoning.  Eupture  of  the  sac,  with  its  fatal 
consequences,  may  also  occur,  or  such  severe  contusions  of  the  tumor 
may  be  occasioned  by  excessive  pressure  as  to  result  in  gangrene  of 
its  entire  mass.  The  development  of  the  foetus  is,  as  a  rule,  not  inter- 
fered with  by  ovarian  tumors.  The  latter  manifest  a  tendency  to  very 
rapid  development  in  the  puerperal  state,  except  in  those  rare  cases 
characterized  by  permanent  retrogressive  metamorphosis  and  absorp- 
tion. 

Ovarian  tumors  are  a  dangerous  complication  of  pregnancy.  Play- 

*  SCHROEDER,  0/?.  C?7.,  p.  501. 


ABNORMALITIES  OF  THE  F(ETUS. 


513 


fair  reports  fifty-seyen  cases,  with  thirteen  deaths.  The  treatment, 
where  the  tumor  interferes  with  delivery,  consists  in  reposition,  or, 
failing  after  persevering  effort,  in  puncture  of  the  cyst.  The  cul-de- 
sao  of  the  vagina  affords  generally  the  most  convenient  point  for 
introducing  the  trocar.  The  time  selected  for  tapping  should  be 
during  the  existence  of  a  pain,  when  the  cyst  is  rendered  tense  by 
pressure.  Owing  to  the  rapid  increase  in  the  size  of  the  tumor  which 
commonly  results  from  pregnancy,  and  in  consideration  of  the  rela- 
tively favorable  issue  of  ovariotomy  performed  upon  pregnant  women, 
the  radical  operation  during  pregnancy  may  possibly  prove  in  the 
future  the  most  advantageous  form  of  treatment. 


CHAPTER  XXIX. 

ABNORMALITIES  OF  THE  FCETUS  WEICH  OFFER  AN  OBSTRUCTION 

TO  DELIVERY. 

Premature  ossification  of  the  cranium. — Hydrocephalus, — Encephalocele. — Hydrothorax. 
— Ascites. — Other  causes  of  abdominal  distention. — Tumors  of  the  trunk. — Mon- 
strosities.— Double  monsters. — Acardiaci. — Anencephalous  monsters. — Abnormal  po- 
sitions.— Spontaneous  version. — Spontaneous  evolution. 

1.  Fetal  Diseases  which  obstruct  the  Expulsion  of  the  Head. 

Premature  Ossification  of  the  Fetal  Craniuin. — This  condition  is 
characterized  by  the  complete  or  nearly  complete  closure  of  the  fonta- 
nelles.  The  head,  therefore,  loses  its  compressibility,  and  no  longer 
undergoes  those  changes  of  form  which  constitute  so  important  a  part 
in  the  mechanical  processes  of  delivery.  As  the  anomaly  is  apt  to  in- 
terfere with  brain  development  in  infancy,  the  late  Dr.  John  E.  Blake* 
advocated  early  perforation  where  the  interests  of  the  mother  had  to 
be  consulted.  As  I  have  never  met  with  this  form  of  dystocia  in  a 
large  number  of  instrumental  deliveries,  I  can  not  but  regard  it  as 
extremely  uncommon. 

Hydrocephalus. — Congenital  hydrocephalus  of  sufficiently  marked 
development  to  constitute  an  impediment  to  parturition  is  compara- 
tively rare,  occurring,  according  to  the  statistics  of  Madame  La  Cha- 
pelle,t  only  fifteen  times  in  43,545  deliveries.  It  consists  usually  in 
a  serous  effusion  confined  to  the  cerebral  ventricles.  The  effusion 
may,  however,  according  to  Jaccoud  and  Hallopean,J;  be  situated  in 
the  meshes  of  the  pia  mater,  in  the  cerebral  parenchyma,  in  the  sub- 
arachnoid cavity,  or  between  the  arachnoid  and  the  dura  mater. 

*  Blake,  "Am.  Jour,  of  Obstct.,"  vol.  xii,  IS'ZO,  p.  225. 
f  Spiegelberg,  "  Lehrbuch,"  p.  525. 

X  "Nouv.  diet,  dc  med.  et  chir.  prat.,"  vol.  xiii,  article  "Enc^phale,"  p.  151. 
33 


514 


THE  PATHOLOGY  OF  LABOR. 


Etiology. — The  etiological  factors  of  the  disease  have  not  been 
ascertained,  although  Herrgott  *  assumes  an  invariable  causative  rela- 
tion between  coexisting  cretinism  and  hydrocephalus. 

Morbid  Anatomy. — The  accumulated  serum  compresses  the  cerebral 
parenchyma  and  produces  dilatation  of  the  cranial  cavity,  which  may 
become  excessive.  The  cranial  bones  become  abnormally  thin,  being 
in  some  instances  no  thicker  than  parchment.  Their  continuity  may 
be  interrupted  by  apertures  of  varying  size,  through  which  the  con- 
tents of  the  cranium  may  protrude,  constituting  an  encephalocele. 
The  skull  is  of  disproportionate  magnitude  as  compared  with  the  face. 
The  head  may  attain  the  dimensions  of  that  of  an  adult.  The  fore- 
head is  prominent  and  bulging,  the  sutures  are  widely  open,  and  the 
fontanelles  of  large  diameter.  The  body  of  the  foetus  is  usually  well 
developed,  and  of  a  size  corresponding  to  the  existing  period  of  preg- 
nancy, although  spina  bifida  and  other  malformations  may  coexist. 
Hydramnion  frequently  complicates  hydrocephalus. 

Diagnosis. — Cystic  tumors,  spina  bifida,  encephalocele,  and  the  skull 
of  a  macerated  foetus,  are  most  frequently  mistaken  for  hydrocephalus. 
The  differential  diagnosis  is  based  upon  different  signs,  according  to 
the  position  and  presentation  of  the  foetus.  If  the  head  present  and 
be  still  above  the  superior  strait,  abdominal  palpation  may  sometimes 
detect  a  large,  rounded,  and  hard  tumor  above  the  pubes,  while  aus- 
cultation discovers  the  maximum  intensity  of  the  fetal  cardiac  sounds 
above  the  umbilicus.  The  abdomen  is  unusually  distended.  If  the 
head  has  descended  somewhat  into  the  pelvic  cavity,  palpation  per 
vag  inamreYesih  a  fluctuating  sac,  which  becomes  notably  tense  dur- 
ing the  pains.  In  the  interval  between  the  uterine  contractions,  the 
broad  fontanelles,  the  thin  bones,  and  the  wide  sutures  are  readily  felt. 
These  signs  may,  however,  fail  if  the  cranial  bones  be  thick  and  the 
sutures  already  ossified.  In  this  case  the  disproportion  between  the 
forehead  and  face,  the  bulging  frontal  bone,  and  the  prominence  of  the 
superciliary  ridges  are  important  aids  to  a  diagnosis.  If  the  mem- 
branes be  ruptured,  the  hairy  scalp  may  be  felt.  The  diagnosis  is 
easier  when  the  cranial  cavity  is  not  greatly  distended.  In  case  of  a 
breech  presentation,  the  diagnosis,  which  is  then  more  difflcult,  must 
chiefly  rest  upon  the  detection,  at  the  fundus,  of  a  tumor  larger  than 
the  normal  fetal  cranium.  The  previous  occurrence  of  hydrocephalus 
in  the  same  subject  and  feeble  fetal  movements  may,  in  this  instance, 
slightly  facilitate  the  task  of  the  diagnostician. 

Mechanism  of  Delivery. — The  course  of  parturition  is  sometimes 
not  materially  impeded  even  by  a  largely  developed  hydrocephalic  foe- 
tus. This  may  be  due,  if  the  bones  be  attenuated,  to  the  ready  mold- 
ing of  the  fetal  cranium  to  the  pelvis,  or  to  rupture  of  the  head  and 

*  Heurgott,  "Des  mal  foetal,  q.  peuvent  faire  obstacle  ^  I'accouch.,"  Paris,  IS^S, 
p.  13. 


ABNORMALITIES  OF  THE  F(ETUS. 


515 


escape  of  the  serum,*  which  event  occurs  chiefly  in  breech  presenta- 
tions. The  presentation  materially  affects  the  course  of  delivery.  If 
the  head  be  forced  with  its  greatest  circumference  against  the  superior 
strait,  it  adapts  itself  less  readily  to  the  pelvis  than  when  it  impinges 
laterally  or  obliquely  on  the  pelvic  entrance.  The  difficulties  of  deliv- 
ery are  increased  if  the  cranial  bones  be  firm  and  thick,  or  the  sutures 
ossified.  Breech  presentations  are  favorable  to  a  speedy  delivery,  in 
that  the  head  is  subjected  during  its  descent  to  more  equable  press- 
ure by  the  pelvic  parietes,  and  therefore  assumes  a  conical  shape  best 
adapted  to  insure  its  easy  expulsion.  Spontaneous  delivery  is,  how- 
ever, rare.  In  the  vast  majority  of  cases  operative  interference  becomes 
necessary. 

Prognosis. — The  child's  life  is  usually  sacrificed  if  the  anomaly  be 
sufficiently  marked  to  considerably  protract  parturition.  Even  if  the 
child  be  born  alive,  it  will  probably  succumb  at  au  early  period  of  ex- 
tra-uterine life.  The  prognosis  with  reference  to  the  mother  depends 
largely  upon  the  time  at  which  obstetrical  aid  is  extended,  and  upon 
the  nature  of  the  remedial  measures  adopted.  If  the  labor  be  too  long 
protracted,  vesico-vaginal  fistula  may  result  from  pressure  of  the  fetal 
head,  or  the  mother  may  die  from  exhaustion  or  from  rupture  of  the 
uterus.  Rupture  of  the  uterus  is  comparatively  frequent,  having  oc- 
curred in  sixteen  out  of  seventy-four  cases  of  hydrocephalus  collected 
by  Thomas  Keith.  The  laceration  usually  occurs  in  the  vicinity  of 
the  cervix,  but  is  often  located  at  the  fundus  uteri.  The  treatment 
consists  in  puncturing  the  head  with  a  fine  trocar  and  allowing  the 
fluid  to  escape.  If  practicable,  the  child  should  be  subsequently 
turned  and  extracted  by  the  feet.  The  forceps  is  useless,  as  it  can 
not  be  made  to  take  a  firm  hold.  If  version  is  found  to  be  attended 
with  difficulty,  the  opening  should  be  enlarged,  and  the  head  extract- 
ed with  the  cranioclast. 

Congenital  Encephalocele. — This  abnormality  of  the  fetal  cranium 
consists  in  the  accumulation  beneath  the  scalp  of  cephalic  fluid,  with 
or  without  an  investment  of  meningeal  or  of  cerebral  tissue.  The  sac 
containing  the  fluid  is  attached  to  the  cranium  by  a  pedicle  of  varying 
length  and  form.  The  aperture  through  which  the  fluid  originally 
contained  within  the  cranium  finds  exit  may  be  produced  by  attenu- 
ation of  the  cranial  bones  attendant  upon  hydrocephalus,  or  may  be 
due  to  arrested  development.  In  some  instances  the  encephalocele  is 
found  still  communicating  with  the  cranial  cavity  through  its  pedicle, 
but  in  others  the  latter  is  impervious.  Encephaloceles  vary  in  size 
from  hardly  perceptible  sacs  to  tumors  of  larger  circumference  than 
the  cranium  itself.  They  may  occupy  any  part  of  the  periphery  of 
the  head,  but  are  most  frequent  in  the  frontal  and  occipital  regions,  f 
The  head  may  itself  be  hydrocephalic  or  normal.    The  cause  of  the 

*  b'cnuoEDKR,  "  Lehrbuch,"  p.  632.  f  IIerrgott,  op.  cit.,  p.  121. 


516 


THE  PATHOLOGY  OF  LABOR. 


anomaly  in  question  is  not  definitely  known,  but  is  inferred  to  be  of 
inflammatory  nature. 

Enceplialoceles  rarely  obstruct  delivery,  because,  their  most  frequent 
seat  being  in  the  frontal  or  occipital  region,  they  are  expelled  either 
before  or  after  the  head.  Their  presence  seems  to  determine  nutritive 
changes  in  the  cranial  bones,  whereby  the  latter,  being  rendered  softer 
and  more  yielding,  are  more  readily  expelled.  The  amount  of  obstruc- 
tion caused  by  the  encephalocele  will  reach  its  maximum  when  the  size 
is  large,  the  pedicle  short,  and  the  seat  lateral ;  but  simple  puncture 
usually  suffices  to  evacuate  the  sac,  and  obviates  further  difficulty.  The 
prognosis  for  both  mother  and  child  is  far  better  than  in  cases  of  con- 
genital hydrocele. 

II.  Abnormal  Conditions  of  the  Fcetus  which  obstruct  the 
Expulsion  of  the  Trunk. 

Hydrothorax. — Hydrothorax,  unattended  by  serous  effusion  into 
any  other  of  the  closed  cavities  of  the  body,  is  infrequent,  and  when 
present  is  rarely  of  sufficient  extent  to  offer  any  impediment  to  deliv- 
ery. Spiegelberg  encountered  only  one  such  case,  and  refers  to  but 
two  others  observed  by  Hohl.* 

Ascites. — Ascites,  although  more  frequent  than  hydrothorax,  ordi- 
narily constitutes  an  insignificant  obstruction  to  parturition,  on  ac- 
count of  the  yielding  character  of  the  abdominal  walls  and  the  small 
amount  of  fluid  usually  present.  It  has,  however,  in  some  instances 
markedly  retarded  delivery,  f 

Ascites  and  hydrothorax  are  more  frequently  associated  than  iso- 
lated, and  present,  when  combined,  no  inconsiderable  obstruction  to 
delivery.  Pericardial  effusions  of  varying  magnitude  may  exist  simul- 
taneously with  either  or  both  these  affections.  J 

The  size  of  the  fetal  abdomen  may  be  so  much  augmented  by  dis- 
tention or  enlargement  of  its  viscera  as  to  obstruct  labor.  Among 
the  causes  of  abdominal  distention  from  this  source  may  be  cited  : 

(a)  Cystic  degeneration  of  the  kidneys ;  *  (b)  dilatation  of  the  uri- 
nary bladder  ;  ||  (c)  dilatation  of  the  ureters  ;  ^  (d)  fibro-cystic  degen- 

*  Spiegelberg,  "  Lehrbuch,"  p.  528. 

f  Martin,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxvii,  1866,  p.  28. 

^  Herrgott,  op.  ciL,  p.  155. 
Cummins,  "Dublin  Jour,  of  Med.  Sci.,"  May,  1873,  p.  499;  Voss,  "Monatsschr.  f. 
Geburtsk.,"  Bd.  xxvii,  1866,  p.  28;  Kanzow, Bd.  xiii,  1859,  p.  182;  Wegscheider, 
Ibid.,  Bd.  xxvii,  1866,  p.  21. 

II  Whittaker,  "Am.  Jour,  of  Obstet.,"  vol.  iii,  1871,  p.  389;  Duncan,  "Edinburgh 
Med.  Jour.,"  August,  1870,  p.  163;  Hartmann,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxvii, 
1866,  p.  273  ;  Rose,  Ibid.,  Bd.  xxv,  1865,  p.  425  ;  Olshausen,  "Arch.  f.  Gynaek,"  Bd-  ii, 
p.  280;  Kristaller,  "Monatsschr.  f.  Geburtsk.,"  Bd.  xxvii,  1866,  p.  165;  Hecker,  Ibid.^ 
Bd.  xviii,  1861,  p.  373. 

^  Ahlfeld,  "  Arch.  f.  Gynaek.,"  Bd.  iv,  p.  161. 


ABNORMALITIES  OF  THE  FCETUS. 


517 


eration  of  a  testicle  still  retained  in  the  abdomen  ;  *  (e)  enlargement 
of  the  liver,  due  to  degenerative  processes ;  f  (/)  enlargement  of  the 
uterus,  produced  by  secretions  accumulated  in  its  cavity,  the  cervix 
being  impermeable  ;t  (ff)  enlargement  of  the  pancreas  ;  *  (h)  enlarge- 
ment of  the  spleen ;  ||  (i)  one  foetus  included  within  another.^  In  this 
case  one  foetus  is  completely  invested  by  the  integument  of  the  other, 
and  is  attached  to  the  latter  by  a  pedicle,  which  is  usually  inserted 
either  in  the  sacro-coccygeal,  perineal,  or  cervical  regions.^  A  case  of 
extensive  anasarca  of  the  foetus,  characterized  by  the  peculiar  gelati- 
nous nature  of  the  fluid  contained  in  the  subcutaneous  cellular  tissue, 
is  reported  by  Keiller  to  have  produced  dystocia.^  Emphysema  of  the 
entire  fetal  trunk  may  result  from  putrefaction  occurring  in  the  tissues 
of  a  child  retained  for  some  time  in  utero  after  the  escape  of  the  am- 
niotic fluid.  J  The  putrefactive  processes  owe  their  origin  to  the  en- 
trance of  air  within  the  uterus.  The  gaseous  products  of  decomposi- 
tion are  developed  in  all  the  fetal  tissues  and  in  the  cavities  of  its 
body.  The  skin  is  distended,  translucent,  and  glistening.  It  crepi- 
tates on  pressure,  and  gas  escapes  from  incisions  carried  through  the 
cuticle.  The  trunk  and  extremities  are  largely  increased  in  volume, 
and  their  augmented  size  offers  an  obstacle  to  delivery  which  the 
uterine  forces,  probably  already  exhausted  by  prolonged  expulsive 
efforts,  can  not  overcome.  In  such  cases  the  bulk  of  the  child  should 
be  diminished  by  punctures  of  the  skin  to  allow  the  gases  to  escape, 
and  when  the  head  presents  it  should  be  extracted  with  the  cepha- 
lotribe.  Tractions  upon  the  extremities  are  liable  to  be  followed  by 
their  separation  from  the  trunk. 

Tumors  developed  in  different  parts  of  the  fetal  trunk  may  disturb 
parturition.  The  most  frequent  site  for  these  tumors  is  the  sacral  and 
perineal  regions,  where  they  are  developed  between  the  sacrum,  the 
coccyx,  and  the  rectum.  Their  size  varies  from  that  of  a  small  wal- 
nut to  that  of  the  fetal  cranium  at  term,  and  it  may  even  exceed  these 
dimensions.  The  tumors  may  be  either  cystic,  fatty,  vascular,  carti- 
laginous, osseous,  or  carcinomatous.  So-called  cysto-hygromata  are 
also  frequently  observed  in  this  situation.  Similar  neoplasms  may  be 
located  in  the  axilla,  upon  the  pectoral  muscles,  and  in  the  anterior  or 
posterior  cervical  regions.  Spina  bifida,  when  accompanied  by  the 
formation  of  a  large  hydrorachitic  sac,  constitutes  another  form  of 
congenital  fetal  tumor,  and  is  most  frequently  observed  in  the  lumbo- 
sacral region.  Ectopia  of  the  abdominal  viscera,  hernias,  hydatid  cysts, 

*  Rogers,  "  Am,  Jour,  of  Obstet.,"  vol.  ii,  p.  626. 

f  ScHROEDER,  "  Lehrbuch,"  p.  634.  %  Spiegelberg,  *'  Lehrbuch,"  p.  528. 

*  Martin,  "  Monatsschr.  f.  Gebuitsk.,"  Bd.  xxvii,  1866,  p,  28. 

\  Voss,  op.  cit.y  p.  26.  ^  Spiegelberg,  "Lehrbuch,"  p.  529. 

^  IIerrgott,  op.  cit.,  p.  266.  ^  Schroeder,  "  Lehrbuch,"  p.  636. 

^  Spiegelberg,  "  Lehrbuch,"  p.  524. 


518 


THE  PATHOLOGY  OF  LABOR. 


and  encysted  neoplasms  of  the  abdominal  walls  sometimes  constitute 
tumors  sufficiently  extensive  to  impede  parturition.  We  may  also  cite 
anchylosis  of  the  fetal  joints,  adliesions  of  the  extremities  to  the 
trunk  or  to  one  another,  and  rigor  mortis,  as  rare  abnormalities  which 
interfere  with  that  pliability  of  the  child  requisite  for  its  adaptation 
to  the  parturient  canal,  and  finally,  adhesion  of  the  foetus  to  the  pla- 
centa or  to  the  uterine  parietes  as  causes  of  dystocia.* 

Diagnosis. — An  accurate  differential  diagnosis  between  these  varied 
morbid  conditions  can,  as  a  rule,  only  be  made  after  delivery.  If 
enlargement  of  the  trunk  be  present,  the  head  or  breech  is  born  with- 
out difficulty,  but,  the  progress  of  parturition  being  then  completely 
arrested,  an  investigation  easily  reveals  the  existence  of  an  abnormally 
large  trunk.  A  hydrorachitic  sac  is  liable  to  be  mistaken  in  a  breech 
presentation  for  the  fetal  membranes.  Its  consistence  is,  however, 
not  altered  by  the  occurrence  of  uterine  contractions,  and  no  fetal 
parts  are  felt  beneath  the  membrane,  which  is  found  to  be  continuous 
with  the  fetal  cutaneous  surface. 

III.  MoiTSTROSITIES. 

Dystocia  is  more  frequently  produced  by  double  monstrosities  than 
by  any  other  variety.  These  are  divided  by  Veit  f  into  three  princi- 
pal classes,  characterized,  respectively,  by — 1.  Incomplete  double  for- 
mation of  the  upper  or  of  the  lower  extremities ;  2.  Two  separate  bod- 
ies united  either  by  their  upper  or  by  their  lower  extremities;  3.  Two 
separate  bodies  attached  to  each  other  either  by  their  abdominal  or 
by  their  dorsal  surfaces. 

Diagnosis. — The  differential  diagnosis  of  the  individual  deformities 
is  usually  impossible  in  the  earlier  stages  of  parturition.  Even  in  the 
succeeding  stages  it  is  difficult,  since  separate  twins  may  present  essen- 
tially the  same  phenomena.  The  diagnostician  will  derive  some  assist- 
ance from  the  facts  that  certain  women  seem  predisposed  to  the  devel- 
opment of  double  monsters,  and  that  certain  smaller  and  easily  recog- 
nizable deformities  of  the  extremities  (as  club-foot)  are  often  merely 
complications  of  more  important  ones,  and  serve  to  indicate  the  exist- 
ence of  the  latter.  The  family  history  may  furnish  valuable  assistance, 
inasmuch  as  the  deformities  under  consideration  are  sometimes  heredi- 
tary. Double  monsters  are  most  frequently  observed  in  multiparae, 
but  this  fact  is  referred  by  Veit  J  to  the  relative  numerical  preponder- 
ance of  the  former  over  primiparse.  When  parturition  has  progressed 
sufficiently  to  allovv  of  introduction  of  the  hand  within  the  uterus, 
should  the  necessities  of  the  case  call  for  this  measure,  the  diagnosis 
becomes  clear. 

*  Whittaker,  "Am.  Jour,  of  Obstet.,"  vol.  iii,  1871,  p.  247. 

f  Vkit,  Volkmann's  "  Samml.  klin.  Vortr.,"  Volkmann,  1879,  Nos.  164,  165. 

X  Veit,  op.  cil.,  p.  1318. 


ABNORMALITIES  OF  THE  FCETUS. 


519 


Mechanism  of  Labor. — The  natural  forces  suffice,  according  to  the 
statistics  of  Playfair  and  Hohl,*  for  the  deliyery  of  double  monsters 
in  more  than  fifty  per  cent,  of  the  cases.  This  fact  may  be  attributed 
to  the  com^^aratiyely  small  dimensions  of  the  foetus  and  to  the  frequent 
occurrence  of  abortion  or  of  premature  delivery  in  cases  of  this  nat- 
ure. The  course  of  parturition  in  a  case  of  the  first  variety  is  simi- 
lar to  that  obtaining  when  the  head  of  a  single  foetus  is  of  unusually 
large  dimensions.  The  second  variety  does  not  ordinarily  seriously 
interfere  with  delivery,  particularly  if  there  be  a  breech  presentation. 
In  this  case  the  bodies  pass  through  the  parturient  canal  simultane- 
ously, lying  parallel  to  each  other.  One  head  then  passes  along  the 
hollow  of  the  sacrum  and  is  first  expelled,  while  the  other  is  retained 
above  the  brim,  its  neck  being  bent  into  close  apposition  to  the  pubes 
until  after  the  expulsion  of  its  fellow.  Should  there,  however,  be  a 
disparity  between  the  lengths  of  the  necks,  both  the  heads  may  simul- 
taneously pass  through  the  pelvic  canal.  When  they  reach  the  outlet, 
the  head  attached  to  the  longer  neck  is  expelled.  The  second  head 
must  then  be  expelled  with  the  neck  and  shoulders  of  the  former. 
Under  these  circumstances,  interference  on  the  part  of  the  obstetrician 
is  usually  required. 

Head  presentations  are  the  most  common  ones  in  cases  of  the  third 
variety,  and  the  course  of  parturition  is  as  follows  :  The  head  of  one 
foetus  is  born,  that  of  the  other  being  detained  above  the  pelvic 
brim.  The  trunk  belonging  to  the  first  head  then  follows.  Next 
comes  the  second  trunk  ;  and,  finally,  the  head  belonging  to  the  latter. 
Spontaneous  delivery,  when  it  occurs,  is  usually  effected  in  this  man- 
ner. Head  presentations  of  the  first  variety,  i.  e.,  those  in  which  a 
single  trunk  possesses  two  heads,  usually  pursue  the  course  just  de- 
scribed. 

Prognosis. — The  prognosis  for  the  child  is  very  unfavorable,  owing 
to  its  expulsion  in  an  undeveloped  condition  and  to  the  compression 
exerted  upon  it  during  labor.  The  prognosis  for  the  mother  is  favor- 
able because  of  the  usual  small  dimensions  of  the  foetus  and  of  the 
freedom  with  which  measures  for  the  reduction  of  its  volume  are 
resorted  to  in  view  of  its  probable  early  demise. 

An  acardiacus  is  a  monster  devoid  of  a  heart.  It  is  developed 
simultaneously  with  a  normal  foetus,  and  is  usually  born  after  the  lat- 
ter. Its  development,  as  already  explained,!  occurs  in  the  following 
manner  :  The  balance  of  circulation  in  the  anastomosing  vascular  sys- 
tems of  twins  contained  in  a  single  chorion  (and  therefore  of  the  same 
sex)  becomes  disturbed,  and  the  pressure  in  one  system  so  preponder- 
ates over  that  in  the  other  that  the  circulation  of  the  latter  is  reversed, 
and  its  heart,  lungs,  and  body  atrophy.  It  now  receives  its  nutritive 
supplies  from  the  normal  foetus.    As  the  result  of  congestion  in  its 

*  SriEGELBERG,  "  Lchrbucli,"  p.  531.  f  Chapter  on  "Multiple  Pregnancy." 


520 


ABNORMALITIES  OF  THE  FCETUS. 


umbilical  vein,  its  connective  tissue  often  undergoes  hypertrophy  and 
oedematous  infiltration.  The  same  cause  may  result  in  hydrocephalus 
or  in  the  development  of  a  monster  presently  to  be  described  as  an 


Fig.  216. — Author's  case  of  acardia. 


anencephalus.  The  most  common  variety  of  acardiacus  is  known  as 
the  acephalus,  or  headless  monster.  The  amorphus  is  an  acardiacus 
without  head  or  extremities.  It  is  of  rounded  form,  and  its  surface, 
though  ordinarily  smooth,  may  present  faintly  marked  tubercles,  which 
are  regarded  as  rudimentary  extremities.  The  interior  of  the  amor- 
phus contains  a  rudimentary  intestinal  canal,  cystic  cavities,  muscles, 
and  vertebrae.  The  umbilical  cord  is  attached  indifferently  to  any 
part  of  the  body.  The  rarest  form  of  the  acardiacus  is  the  acormus, 
or  trunkless  monster.    It  consists  of  an  imperfectly  developed  head 


ABNORMALITIES  OF  THE  F(ETUS. 


521 


with  a  rudimentary  trunk.  Its  umbilical  cord  is  attached  to  the  cer- 
vical region. 

An  anencephalus  or  hemiceplialiis  is  a  monster  with  a  well-developed 
trunk  and  a  rudimentary  body.  The  neck  is  short  and  the  head  rests 
directly  upon  the  shoulders,  which  are  so  unusually  broad  as  to  consti- 
tute an  impediment  to  delivery.  The  amount  of  amniotic  fluid  is 
ordinarily  large.  The  face  is  turned  upward  and  the  eyes  are  prom- 
inent. The  most  common  presentations  for  an  anencephalus  are  the 
transverse  and  the  breech.  Sometimes  the  face  or  the  exposed  base  of 
the  skull  presents.  In  such  a  case  the  diagnosis  may  be  made  by 
recognizing  the  sella  turcica  and  other  bony  prominences  of  the  base. 
Reflex  actions  may  be  produced  by  irritation  of  the  medulla,  as  it  rests 
exposed  upon  the  basilar  process  of  the  occipital  bone.*  This  deform- 
ity produces  obstruction  by  permitting  other  extremities  to  enter 
the  pelvic  cavity  simultaneously  with  the  diminutive  head,  and  by  the 
unusual  breadth  of  its  shoulders.  The  latter  are  more  readily  ex- 
pelled when  the  parturient  canal  has  been  previously  dilated  by  the 
passage  of  the  breech. 

Spoktaneous  Version. 

The  term  spontaneous  version  is  applied  to  the  process  by  which 
either  a  transverse  position  is  transformed  through  Nature's  unaided 
efforts  into  a  longitudinal  one,  or  to  that  by  which  a  normal  position 
is  either  partially  or  completely  reversed.  Spontaneous  version,  which 
occurs  during  pregnancy  as  a  very  frequent  physiological  phenome- 
non, is  observed  with  comparative  infrequency  during  labor.  It  may 
be  partial  or  complete,  according  as  the  presenting  member  is  dis- 
placed laterally  through  either  90°  or  180°,  may  occur  before  or  after 
the  rupture  of  the  membranes,  and  may  result  in  the  transformation 
of  a  transverse  position  into  either  a  head,  a  breech,  or  a  footling  pres- 
entation. According  to  the  statistics  of  Hausemann,f  cases  of  spon- 
taneous version  after  rupture  of  the  membranes  are  nearly  five  times 
as  frequent  as  those  occurring  before  their  rupture.  The  same  author 
states  that  the  head  presented  in  eighty  per  cent,  of  the  cases  occur- 
ring before  rupture  of  the  membranes,  and  the  breech  in  seventy-five 
per  cent,  of  those  taking  place  after  the  occurrence  of  that  event. 
SpiegelbergJ  cites  two  cases  from  his  own  practice  in  which  there 
was  an  escape  of  so-called  "  false  waters,"  the  real  membranes  remain- 
ing intact,  and  attributes  the  occurrence  of  spontaneous  version  in 
such  instances  to  the  change  of  uterine  form  rendered  possible  by  the 
evacuation  of  the  false  waters. 

Etiology. — Among  the  conditions  predisposing  to  spontaneous  ver- 

*  Herrgott,  op.  cit.,  p.  263. 

f  IIausemann,  "  Monatsschr.  f,  Gehurtsk.,"  Bd.  xxiii,  1864,  p.  366. 
X  SriEGELBERG,  "Lehrbuch,"  p.  539. 


522 


THE  PATHOLOGY  OF  LABOR. 


sion  is  the  uterine  atrophy  incident  to  repeated  deliveries.  About 
two  thirds  of  all  the  women  in  whom  spontaneous  version  occurs  are, 
accordingly,  multiparas,*  and  their  average  age  is  thirty  years.  Spon- 
taneous version  often  recurs  during  several  consecutive  pregnancies  of 
the  same  individual.  It  is  more  apt  to  occur  during  deliveries  effected 
at  term  than  in  abortions  or  premature  deliveries.  A  living  foetus  is 
more  frequently  the  subject  of  spontaneous  version  than  a  dead  one, 
and  many  authors  attribute  an  important  agency  in  the  production 
of  the  altered  position  to  the  active  movements  of  the  child.  The 
uterine  contractions  are  necessarily  weak  in  cases  of  spontaneous  ver- 
sion occurring  before  the  rupture  of  the  membranes,  as  powerful  pains 
would  force  the  presenting  part  still  farther  into  the  dilated  os  and  fix 
it  immovably  in  the  pelvic  brim.  On  the  other  hand,  the  contrac- 
tions of  the  uterus  during  a  spontaneous  version  which  takes  place 
after  the  escape  of  the  amniotic  fluid  must  be  strong,  as  will  be  ex- 
plained in  our  remarks  on  the  mechanism  of  the  process  in  question. 
An  undilated  cervix,  powerful  contractions  of  the  uterine  fibers,  and 
a  fully  developed  child  are  essential  conditions  for  the  occurrence  of 
spontaneous  version  after  rupture  of  the  membranes.  Some  authors 
consider  the  presence  of  a  certain  amount  of  amniotic  fluid  indis- 
pensable to  the  occurrence  of  spontaneous  version  in  those  cases  taking 
place  after  rupture  of  the  membranes.  It  is  also  necessary  in  such 
instances  that  the  shoulder  or  other  presenting  part  be  freely  mov- 
able, not  having  yet  been  firmly  fixed  in  the  cervical  or  pelvic  canal. 

Mechanism  of  Partial  Version. 

1.  Before  Rupture  of  the  Memhranes.  — In  this  case  the  shoulder 
usually  presents,  the  head  being  lower  than  the  breech.  The  os  is 
only  partly  dilated.  The  woman  having  assumed  a  position  upon 
that  side  of  her  body  toward  which  the  head  is  directed,  the  breech 
tends  to  descend  under  the  influence  of  gravitation,  while  the  head 
is  thus  approximated  to  the  cervix.  The  contractions  of  the  oblique 
and  longitudinal  uterine  fibers  now  complete  the  version  by  exerting 
pressure  upon  the  breech.  When  the  uterus  has  once  regained  its 
natural  shape,  the  normal  position  is  retained  by  the  foetus  until  the 
completion  of  parturition.  In  other  instances,  the  breech  being  lower 
than  the  head,  the  same  mechanism  leads  to  a  breech  or  to  a  footling 
presentation. 

2.  After  Rupture  of  the  Membranes. — In  this  variety  of  spontane- 
ous version  the  amniotic  fluid  has  partially  or  entirely  escaped,  allow- 
ing the  foetus  to  be  tightly  grasped  by  the  uterine  muscular  walls, 
which,  therefore,  labor  under  a  mechanical  disadvantage.  The  os  is 
only  partially  dilated.  The  pains  force  the  presenting  part  into  close 
contact  with  the  os  internum.    Owing  to  the  absence  of  an  equally 

*  Hausemann,  loc.  cit.,  p.  212. 

/ 


ABNORMALITIES  OF  THE  FCETUS. 


523 


distending  bag  of  waters,  the  os  does  not  dilate,  and  soon  assumes  a 
condition  of  tetanic  spasm,  during  which  it  can  be  felt  as  an  unyield- 
ing, cartilaginous  ring.  The  contractions  of  the  oblique  and  trans- 
verse fibers  at  the  fundus  uteri  haying  now  become  more  forcible,  the 
fetal  head  or  breech,  as  the  case  may  be,  is  subjected  to  violent  press- 
ure. Inasmuch,  however,  as  the  unyielding  os  prevents  any  progress 
downward,  the  presenting  part  is  displaced  laterally,  and  that  part  of 
the  foetus  which  previously  occupied  the  fundus  is  forced  into  the 
pelvic  entrance.  The  uterus  next  regains  its  natural  form,  the  os 
dilates,  and  delivery  is  accomplished. 

Mechanism  oe  Complete  VEEsioi^. 

Cases  of  complete  version,  which  are  very  rare,  consist  in  the  trans- 
formation of  one  normal  longitudinal  presentation  into  the  diametrical- 
ly opposite  one,  the  part  originally  presenting  having  rotated  through 
180°.  The  mechanism  is  essentially  identical  with  that  just  described. 
Version  of  this  variety  is  only  likely  to  occur  when  the  amount  of 
liquor  amnii  is  large  and  the  child  small,  so  that  it  is  freely  movable. 
Spontaneous  version  before  the  rupture  of  the  membranes  occupies 
only  half  the  time  required  for  its  accomplishment  after  their  rupture. 
Twenty-four  or  thirty  hours  are  often  necessary  for  the  completion 
of  the  latter  variety.  Delivery,  too,  is,  accomplished  more  speedily  in 
cases  of  the  former  kind  when  version  has  once  occurred. 

Prognosis. — The  prognosis  for  both  mother  and  child  is  good  in 
spontaneous  version  before  rupture  of  the  menabranes,  but  is  graver 
when  the  turning  occurs  after  that  event,  contrasting  unfavorably  with 
manual  version,  owing  to  the  fact  that  injurious  pressure  is  liable  to 
be  exerted  upon  the  prolapsed  cord. 

Spontaneous  Evolution. 

Spontaneous  evolution  is  the  process  by  which  a  shoulder  presenta- 
tion is  transformed,  within  the  true  pelvis,  into  a  combined  breech 
and  shoulder  presentation,  and  spontaneous  delivery  is  then  effected. 
Since  this  may  be  accomplished  in  two  different  ways,  there  are  two 
corresponding  varieties  of  spontaneous  evolution.  The  former  was, 
according  to  Leishman,*  first  described  by  Douglas,  of  Dublin,  as 
spontaneous  expulsion."  Dr.  Taylor  f  takes  exception  to  Leish- 
man's  statement,  and  affirms  that  the  term  spontaneous  evolution 
was  applied  by  Douglas  to  the  mode  of  delivery  in  question.  The  lat- 
ter was  described  by  Roderer  as  birth  with  double  body"  {"  evohi- 
tio  condujylicato  corjjore^^),  and  more  thoroughly  explained  by  Klein- 
wiichter.  J; 

*  Leishman,  "A  System  of  Midwifery,"  Philadelphia,  1873,  p.  337. 

f  Tarmer  ct  Chantreuil,  "Traite  dc  Tart  dcs  accouchements,"  Paris,  1880,  p.  672. 

X  Kleinwachtek,  "Arch.  f.  Gynack.,"  Bd.  ii,  p.  111. 


524 


THE  PATHOLOGY  OF  LABOR. 


Etiology. — Various  conditions  contribute  to  the  facility  with  which 
this  process  is  accomplished  by  Nature.  The  most  important  are 
powerful  pains,  a  roomy  pelvis,  and  a  small  foetus.  Of  these  condi- 
tions, the  first  only  is  essential ;  Grenser  *  has  demonstrated  that  a 
contracted  pelvis  is  not  an  insurmountable  obstacle  to  spontaneous 
evolution  provided  the  conjugate  diameter  be  alone  shortened.  Nor 
is  small  size  of  the  foetus  essential  to  the  occurrence  of  the  process  in 
question.  Spiegelberg  f  states  that  it  is  often  observed  in  cases  where 
the  foetuses  are  mature  and  well  developed.  Softness  and  compressi- 
bility of  the  child  naturally  favor  the  production  of  spontaneous  evo- 
lution, as  is  demonstrated  by  its  frequent  occurrence  when  the  product 
of  conception  has  undergone  maceration. 

Mechanism. — The  mechanism  of  the  former  and  more  ordinary 
variety  of  spontaneous  evolution  is  as  follows  :  The  presenting  shoulder 
is  forced  into  the  depths  of  the  true  pelvis  by  the  violence  of  the  uter- 
ine contractions,  instead  of  being  diverted  laterally,  as  is  the  case  in 
spontaneous  version,  and  becomes  firmly  fixed  beneath  the  symphysis, 
while  the  corresponding  arm  protrudes  through  the  vulva.    The  body 


of  the  foetus  is  then  so  forcibly  flexed  that  the  breech  and  the  head  lie 
in  close  proximity  to  each  other.  The  former  is  in  contact  with  the 
sacro-iliac  synchondrosis,  while  the  latter  is  immovably  held  between 
the  breech  and  the  upper  border  of  the  symphysis.  The  neck  and 
shoulder,  which  rest  against  the  lower  border  of  the  symphysis,  now 
become  the  pivot  upon  which  the  foetus  rotates.    The  trunk  of  the 


Fig.  217.— Birth  with  doubled  body.  (Chiara.) 


*  Grenser,  *'  Monatsscbr.  f.  Gcburtsk.,"  Bd.  xxvii,  1SG6,  p.  445. 
f  Spiegelberg,  "Lehrbuch,"  p.  541. 


ABNORMALITIES  OF  THE  F(ETUS. 


525 


foetus  is  driven  beyond  the  shoulder,  and  the  thorax,  breech,  and  legs 
are  born  in  the  order  named.  The  other  shoulder  then  follows,  and 
the  head  is  finally  expelled. 

The  mechanism  of  the  second  variety  of  spontaneous  evolution, 
designated  by  Koderer  evolutio 
condupUcato  corpore"  which  is 
much  rarer  than  the  former,  dif- 
fers from  it  in  some  essential  feat- 
ures. It  is  greatly  facilitated  by 
softness  and  compressibility  of 
the  child,  and  therefore  occurs 
predominantly  in  cases  of  macer- 
ated foetus.  It  is  rarely  observed 
in  other  cases,  unless  the  foetus 
be  unusually  small  and  its  tissues 
greatly  relaxed. 

The  shoulder  is  in  this  in- 
stance forced  downward  and  im- 
prisoned beneath  the  symphysis 
pubis,  as  in  the  former  variety, 
while  the  arm  protrudes  from  the 
vulva.  The  trunk  having  been 
enormously  flexed,  the  head  and 
thorax  simultaneously  enter  the 
pelvic  cavity,  the  former  being 
deeply  imbedded  in  the  latter. 
The  second  arm  and  shoulder  lie 
between  the  breech  and  thorax  on 
the  one  hand,  and  the  head  on 
the  other.  The  presenting  shoul- 
der having  been  expelled,  the  head 
and  thorax  are  born  together,  and 
these  are  followed  by  the  breech 
and  the  legs. 

Prognosis. — The  prognosis  in 
spontaneous  evolution  is  good  for  the  mother  but  very  bad  for  the 
foetus,  since  only  immature  children  are,  as  a  rule,  able  to  pass 
through  the  ordeal  of  delivery  by  this  method  alive.  This  remark 
applies  with  special  force  to  children  born  by  the  variety  of  sponta- 
neous evolution  known  as  "evolutio  conduplicato  corpore.^''  Dr.  Tay- 
lor* recommends,  when  the  perinseum  is  distended  by  the  doubled 
body  of  the  child,  to  make  lateral  incisions  to  the  extent  of  three  to 
four  inches  at  the  vulva,  and  thus  remove  the  obstacle  to  delivery 
afforded  by  the  pelvic  floor. 

*  Taylor,  "Am.  Jour,  of  Obstet.,"  July,  1881,  p.  532. 


Fig.  218. — Neglected  shoulder  presentation.  Sec- 
tion through  frozen  corpse.  (Kleinwachter.) 


526 


THE  PATHOLOGY  OF  LABOR. 


CHAPTER  XXX. 

ECLAMPSIA. 

Definition. — Clinical  history. — Prognosis,  pathology,  and  etiology. — Treatment. 

Eclampsia  is  the  term  applied  to  convulsions,  tonic  and  clonic  in 
character,  the  foundation  of  which  is  laid  in  processes  connected  with 
pregnancy,  labor,  and  childbed  (eclampsia  gravidarum,  parturien- 
tium,  vel  puer per  arum).  By  this  definition  it  is  intended  to  exclude 
the  convulsions  due  to  hysteria,  true  epilepsy,  and  cerebral  lesions, 
which  occurrences  in  pregnancy  are  to  be  regarded  simply  as  accidental 
complications.  In  eclampsia  there  is  loss  of  consciousness  during  the 
attacks,  with  at  first  a  disturbance  of  the  intellectual  faculties  in  the 
intervals,  deepening  in  severe  cases  into  coma.  Before  entering  upon 
a  discussion  as  to  the  probable  nature  of  this  affection,  it  is  proper  to 
present  a  summary  of  its  clinical  manifestations. 

Clinical  History. — Eclampsia  is  fortunately  a  tolerably  rare  event. 
Its  estimated  frequency  is  in  about  the  proportion  of  once  in  five 
hundred  pregnancies.  The  total  number  of  deaths  from  this  cause 
reported  to  the  Board  of  Health  in  New  York  City,  in  the  nine  years 
from  1867  to  1875  inclusive,  was  408.  The  estimated  maximum  num- 
ber of  deliveries  during  that  period  was  284,000,  or  nearly  one  death 
to  seven  hundred  confinements.  The  entire  number  of  deaths  occur- 
ring in  pregnant  women  from  all  causes  during  the  same  period  was 
3,342,  making  the  proportion  of  those  from  eclampsia  as  one  to  eight. 
In  the  majority  of  cases,  though  not  invariably,  premonitory  symp- 
toms announce  the  impending  outbreak.  Of  these  the  most  impor- 
ant  are  headache,  often  limited  to  one  side,  vertigo,  loss  of  memory, 
gloomy  forebodings,  flashes  of  light  before  the  eyes,  contracted  pupils, 
amblyopia,  sometimes  amaurosis,  ringing  in  the  ears,  dyspepsia,  nausea, 
vomiting,  dyspnoea,  oedema  of  the  face,  of  the  labia  majora,  and  of 
the  extremities,  and,  finally,  and  of  first  importance,  the  presence  of 
albumen  and  of  casts  in  the  urine. 

The  attacks  resemble  those  of  epilepsy,  the  cry  only  lacking.  When 
they  occur  during  labor,  the  first  convulsion  often  is  preceded  by  a 
short  calm,  in  which  the  patient  ceases  to  complain,  closes  her  eyes, 
and  seems  to  have  sunk  into  a  peaceful  slumber.  This  deceitful  truce, 
which  should  always  excite  the  keen  attention  of  the  physician,  is  fol- 
lowed in  a  few  minutes  by  convulsive  movements  of  the  orbicularis 
oris  muscle,  giving  to  the  patient  a  smiling  aspect.  Suddenly  the  eye- 
lids open,  the  eyes  become  fixed,  and  the  pupils  contract.  Then,  in  a 
few  seconds,  the  eyelids  open  and  shut  rapidly,  the  eyes  move  from  side 
to  side  or  roll  upward,  while  the  pupils  dilate  and  lose  their  sensitive- 
ness to  light.    Very  rapidly  the  convulsive  twitchings  extend  to  the 


ECLAMPSIA. 


527 


other  muscles  of  the  face,  the  mouth  opens  and  is  drawn  to  one  side, 
the  head  is  moved  from  shoulder  to  shoulder,  sometimes  with  light- 
ning-like alternations.  Frequently,  for  the  first  two  or  three  convul- 
sions, the  movements  of  the  extremities  are  limited  to  the  pronation 
and  supination  of  the  forearm  and  to  the  closing  of  the  fingers  upon 
the  thumb.  Afterward  the  arms,  crossed  upon  the  thorax,  pass  from 
flexion  to  extension  with  great  rapidity.  The  movements,  as  a  rule, 
are  more  pronounced  in  the  upper  than  in  the  lower  extremities. 
Sometimes  the  latter  are  fixed  with  tetanic  rigidity,  while  at  others 
they  are  flexed  at  the  knee  and  then  drop  of  their  own  weight,  now 
upon  one  side,  now  upon  the  other. 

As  a  consequence  of  the  resulting  disturbances  in  the  circulation 
and  respiration,  the  carotids  pulsate  with  great  distinctness,  the  super- 
ficial veins  of  the  neck  swell,  the  conjunctivae  become  injected,  and 
the  face  is  cyanosed  ;  the  heart's  action  becomes  intermittent,  and  the 
breathing  irregular  and  stertorous. 

In  the  tonic  convulsions,  which  occur  intercurrently  with  clonic 
ones,  the  head  is  inclined  to  one  side,  the  mouth  is  drawn  in  the  same 
direction,  the  jaws  are  closed,  the  eyes  are  fixed,  opisthotonos  or  pleu- 
rosthotonos  develops,  the  pulse  becomes  small  and  intermittent,  the 
respiration  is  suspended,  the  body  becomes  covered  with  a  cold,  clam- 
my sweat,  and  often  involuntary  micturition  or  defecation  takes  place. 
The  tetanic  condition,  after  lasting  from  fifteen  to  thirty  seconds, 
gradually  diminishes  in  intensity. 

As  the  convulsions  cease,  the  distortion  of  the  face  disappears,  the 
cyanosis  diminishes,  the  eyelids  droop,  the  mouth  opens,  and  frothy 
saliva,  tinged  with  blood,  escapes  from  the  mouth  and  nostrils.  Ster- 
torous respiration  marks  the  beginning  of  sopor.  At  first  the  pa- 
tient, unless  the  attack  has  been  of  unusual  severity,  can  be  roused 
when  spoken  to.  The  depth  of  the  sopor  is  proportioned  to  the  vio- 
lence and  frequency  of  the  attacks.  When  the  convulsions  are  repeat- 
ed, the  patient  in  the  intervals  can  no  longer  be  made  to  respond  to 
inquiries,  but  passes  into  a  state  of  complete  unconsciousness.  The 
duration  of  a  single  attack  rarely  exceeds  a  minute,  and  in  tlie  major- 
ity of  cases  lasts  from  ten  to  thirty  seconds.  On  account  of  the  impli- 
cation of  the  respiratory  muscles,  attacks  of  long  duration  are  scarcely 
compatible  with  continued  existence  (Spiegelberg). 

After  a  single  seizure  the  sopor  usually  disappears  in  from  one  half 
to  two  hours,  and  seldom  persists  beyond  a  single  day.  The  number 
of  seizures  in  a  single  day  may,  however,  be  exceedingly  numerous. 
Thus,  seventy  convulsions  have  been  reported  by  Braun,*  eighty-one 
by  Brummerstedt,!  and  one  hundred  and  sixty  by  Depaul.J 

*  Braun,  "  Lehrbucli  der  gosammt.  Gynaekologie,"  p.  822. 
f  Drummerstkdt,  "Beiicht,"  etc.,  Pvostock,  1866. 
X  Vide  Si'iEGELUEnG,  lot:  cit.^  p.  556. 


528 


THE  PATHOLOGY  OF  LABOR. 


With  very  rare  excei3tions — of  which,  however,  I  have  never  seen 
an  example — the  urine  after  the  convulsions  is  found  loaded  with 
albumen,  and  contains  an  abundance  of  renal  epithelium,  often  in  a 
state  of  fatty  degeneration,  casts,  and  sometimes  blood-corpuscles.  In 
all  cases  of  exceptional  severity  the  urine  is  scant  or  absent  altogether. 

Terminations. — In  favorable  cases,  after  the  expulsion  of  the  ovum 
the  attacks  cease  or  diminish  in  frequency  and  intensity,  tlie  pulse 
and  respirations  become  quiet,  and  the  coma  passes  gradually  into  gen- 
tle slumber.  On  awakening  the  patient  complains  of  headache  and  of 
impaired  memory,  and  possesses  no  recollection  of  the  perils  through 
which  she  has  passed.  Pains  are  felt  in  the  muscles,  and  in  the  tongue 
when  the  latter  has  been  injured  to  any  considerable  extent  by  the 
teeth. 

But  even  after  consciousness  returns  the  danger  is  still  not  ended. 
Eclampsia  predisposes  to  post-partum  haemorrhage  and  to  puerperal 
inflammations  ;  or  it  may  leave  behind  hemiplegia,  amblyopia,  an  en- 
feebled mental  condition,  or  psychical  disturbances,  especially  mania, 
which,  however,  usually  terminates  spontaneously  in  the  course  of  the 
first  three  days. 

In  fatal  cases  death  results  from  carbonic-acid  poisoning,  due  to 
tetanus  of  the  respiratory  muscles  or  to  exhaustion  of  the  nervous 
system.  Bailly  relates  the  history  of  a  patient  who  died  of  asphyxia, 
due  to  swelling  of  the  tongue. 

Of  anatomical  lesions  found  in  post-mortem  examinations,  the  most 
constant  are  hyperaemia,  fatty  degeneration,  and  atrophy  of  the  kid- 
neys. The  latter  is  rare,  and  in  many  cases  the  renal  changes  are  of 
moderate  extent.  In  thirty-two  examinations,  Lohlein  *  found  in  eight 
dilatation  of  one  or  both  ureters  and  of  the  pelves  of  the  kidneys.  The 
same  author  likewise  has  demonstrated  the  existence  of  enlargement 
of  the  heart  (the  comparisons  were  instituted  with  those  of  other  preg- 
nant women),  indicative  of  increased  arterial  tension.  The  brain- 
lesions  were  in  most  instances  insignificant. 

Prognosis. — The  prognosis  is  always  serious.  In  Dohrn's  collec- 
tion of  747  cases  the  death-rate  reached  29  per  cent. ;  in  104  cases  col- 
lected by  Hofmeierf  in  Schroeder's  Clinic  the  mortality  was  32*4  per 
cent.  A  better  showing  is  made  by  Braun,J;  who  was  able  to  report 
from  Vienna  in  ten  years,  from  1869  to  1878,  73  cases,  with  twenty 
deaths  (26  per  cent.),  five  from  peritonitis,  and  fifteen  from  Bright's 
disease  alone. 

The  earlier  the  convulsions  occur  in  labor,  the  more  unfavorable 
the  prognosis.  This  is  well  shown  by  the  statistics  of  Lohlein.  Thus, 
of  eighty-three  cases  where  the  first  convulsions  occurred  before  or 

*  Lohlein,  "  Bemerkungcn  zur  Eklumpsiefragc,"  "  Ztschr.  f.  Geburtsh.  und  Gynaek.," 
Bd.  iv,  Heft  1,  p.  89. 

f  HoFMEiER,  loc.  cit.  \  BnAUN,  "  Lclirbuch  dcr  gcs.  Gynaek.,"  p,  833. 


ECLAMPSIA. 


529 


during  the  first  stage  of  labor,  40 '5  per  cent,  of  the  patients  died.  Of 
fifteen  cases  where  the  first  stage  was  completed,  but  one  patient  died. 
Eclampsia,  which  develops  first  in  childbed,  usually  pursues  a  favor- 
able course.  Lohlein  reports  eight  cases,  with  one  death,  which,  how- 
ever, was  the  result  of  infection. 

The  longer  the  labor  the  more  difficult  the  delivery,  the  deeper  the 
coma  ;  and,  the  greater  the  insufficiency  of  the  kidneys,  the  more  de- 
pressing is  the  outlook. 

It  is  very  rare  for  the  convulsions  to  cease  previous  to  the  expulsion 
of  the  child.  According  to  C.  Braun,  after  delivery  in  thirty-seven 
per  cent,  the  convulsions  cease  entirely,  in  thirty-one  per  cent,  they 
become  feebler,  while  in  thirty-two  per  cent,  they  continue  for  a  time 
with  undiminished  severity.  In  childbed  it  is  of  favorable  import 
when  copious  diuresis  sets  in,  and  is  followed  by  the  disappearance  of 
the  albumen  and  of  the  oedema. 

As  regards  the  children  of  eclamptic  women,  it  is  estimated  that 
fully  one  half  are  born  dead,  a  result  probably  due  to  asphyxia  from 
the  accumulation  of  carbonic  acid  in  the  blood  of  the  mother.  As  the 
results  depend  upon  the  number  and  duration  of  the  attacks,  it  is 
evident  that  the  danger  is  greatly  lessened  after  the  completion  of  the 
first  stage  of  labor. 

Pathology  and  Etiology. — As  in  discussions  upon  eclampsia  it  is 
evident  that  the  treatment  advocated  by  physicians  is  governed  almost 
exclusively  by  theoretical  considerations,  it  becomes  of  the  utmost  im- 
portance to  place  before  the  student  an  exact  statement  of  known  facts, 
with  an  attempt  to  estimate  at  their  true  value  the  deductions  which 
various  observers  have  drawn  from  them. 

Now,  in  the  first  place,  in  reviewing  the  foregoing  history  of  the 
disease,  we  are  brought  face  to  face  with  the  very  striking  coinci- 
dence in  the  vast  majority  of  cases  between  renal  insufficiency  and 
the  convulsive  seizures.  This  insufficiency  may  or  may  not  be  as- 
sociated with  albuminuria,  though  the  two  go  pretty  constantly  to- 
gether. 

The  honor  of  first  drawing  attention  to  the  relations  between  albu- 
minuria and  puerperal  convulsions  belongs  to  Dr.  John  C.  W.  Lever, 
who  reported  in  Guy's  Ilosj^ital  Reports,"  second  series,  1842,  four- 
teen cases,  in  ten  of  which  the  urine  was  examined.  Albumen  was 
found  in  greater  or  less  quantity  in  nine  cases;  in  the  post-mortem 
made  in  the  tenth  case  the  death  was  discovered  to  have  been  due  to 
acute  meningitis.* 

These  observations  were  followed  by  others  from  British  physi- 
cians, among  whom  may  be  mentioned  Simpson,  Garrod,  Cormack,  and 

*  Vide  Tyson,  "The  Causal  Lesions  of  Puerperal  Convulsions,"  Philadelphia,  18*79. 
To  this  excellent  summary  I  desire  to  acknowledge  my  indebtedness  for  a  deal  of  labor 
saved,  as  regards  the  search  for  references. 
34 


530 


THE  PATHOLOGY  OF  LABOR. 


Rees  ;  and  in  France  treatises  upon  the  subject  were  published  by 
Cohen  and  Delpech,  and  by  Devilliers  and  Eegnault. 

In  1851  Frerichs  pointed  out  clearly  the  close  resemblance  between 
the  convulsions  occurring  in  pregnancy  and  the  uraemic  convulsions 
of  Bright's  disease.  After  reviewing  the  evidence  with  scientific  pre- 
cision he  concluded  that  *Hrue  eclampsia  occurs  only  in  pregnant 
women  suffering  with  Bright's  disease,  and  it  bears  to  the  latter  the 
same  causal  relation  as  convulsions  and  coma  in  Bright's  disease  in 
general ;  it  is  the  result  of  the  uraemic  intoxication,  with  which  also 
in  its  mode  of  manifestation  it  agrees."  To  this  view  Braun,  in  the 
same  year,  and  Wieger,  in  1854,  brought  effective  support  by  the  pub- 
lication of  a  great  number  of  observations  confirmatory,  both  in  re- 
spect to  the  clinical  features  and  the  post-mortem  appearances,  of  the 
uraemic  origin  of  puerperal  convulsions.  In  1857  Braun  published 
one  of  the  most  meritorious  treatises  upon  midwifery  to  be  found  in 
any  language.  In  this  work  the  new  doctrine  was  presented  with  so 
much  skill  and  clearness  that  since  then,  in  the  minds  of  the  great 
body  of  practitioners,  the  terms  eclampsia  and  uraemia  have  come  to 
be  regarded  as  synonymous.  Now,  though  the  lapse  of  time  has 
tended  to  modify  in  many  respects  the  less  essential  features  of  the 
Frerichs-Braun  thesis,  and  though  many  of  the  earlier  claims  have  had 
to  be  discarded,  the  evidence  which  has  accumulated  from  every  medi- 
cal man's  experience  during  the  last  quarter  of  a  century  has  contrib- 
uted to  place  the  central  idea  upon  an  impregnable  basis.  The  differ- 
ences which  separate  writers  on  the  subject  at  the  present  day  are 
less  differences  of  creed  than  of  definition. 

But,  in  order  to  understand  the  present  position  of  the  question,  it 
is  necessary  to  review  the  objections  which  the  uraemic  theory  has  had 
to  encounter.  Among  its  earliest  opponents  was  Seyfert,  of  Prague, 
who,  occupying  the  vantage-ground  as  director  of  the  maternity  hos- 
pital of  that  place,  second  only  in  size  to  the  great  maternity  at 
Vienna,  furnished  the  clinical  counter-experiences  which  have  since 
proved  the  most  effective  weapons  in  the  hands  of  those  who  have  re- 
garded the  new  doctrine  as  specious  and  heretical.  The  facts  which,  he 
insisted,  invalidated  the  claims  of  Frerichs  and  Braun  were  as  follows  : 

1.  That  convulsions  may  occur  without  albuminuria. 

2.  That  the  albuminuria  is  in  many  cases  the  effect  and  not  the 
cause  of  the  convulsions. 

3.  That  in  many  fatal  cases  the  kidney-lesions  were  absent  or 
wholly  insignificant. 

4  That  convulsions  are  rare  in  chronic  Bright's  disease  which  had 
existed  prior  to  pregnancy. 

*  As  I  have  copied  this  list  from  notes  taken  from  the  lectures  of  Seyfert,  delivered 
in  the  summer  session  of  1865,  I  shall  not  consider  it  necessary  to  more  than  incidentally 
refer  to  the  corroborative  testimony  since  advanced  in  support  of  their  validity. 


ECLAMPSIA. 


531 


5.  That  in  true  uraemia,  sucli  as  necessarily  is  produced  by  the 
suppression  of  urine  when,  in  uterine  cancer,  the  ureters  are  invaded, 
convulsions  do  not  occur. 

That,  in  the  main,  these  propositions  are  correct,  hardly  admits  of 
question.  But,  in  drawing  conclusions  from  these,  unnecessary  stress 
is  laid  upon  the  presence  or  absence  of  albumen  in  the  urinary  secre- 
tion. It  is  the  renal  insufficiency,  it  should  be  fixed  in  the  mind,  and 
not  the  albuminuria,  which  causes  uraemia  and  convulsions.  The  mere 
absence  of  albumen  from  the  urine  does  not  even  exclude  the  existence 
of  Bright's  disease.  Braun  is  careful  to  note  that  in  certain  cases  of 
fatal  eclampsia,  in  spite  of  the  absence  of  albuminuria,  the  post-mortem 
examination  revealed  amyloid  degeneration  of  the  kidneys  and  of  the 
heart-structures ;  and,  again,  in  others,  of  atrophy  of  both  kidneys, 
where  the  dropsy,  and  the  albumen,  and  casts,  which  had  been  present 
earlier  in  i^regnancy,  had  entirely  disappeared  at  the  moment  the  con- 
vulsions occurred.  Bailly  has  shown  that  not  rarely  albuminuria  in 
pregnant  women  may  disappear  for  several  hours  and  then  reappear 
once  more,  so  that  it  is  possible  for  an  examination  to  be  made  during 
the  short  period  when  the  urine  ceases  to  be  albuminous. 

On  the  other  hand  chronic  nephritis  does  not  necessarily  imply 
insufficiency  of  the  renal  secretion.  Seyfert  reported  over  70  cases 
where  women  suffering  from  Bright's  disease  became  pregnant ;  only 
two  of  these  had  convulsions.  Every  observer  has  seen  similar  in- 
stances of  immunity.  Nephritis  in  pregnancy  brings  with  it  its  own 
peculiar  dangers.  Of  forty-six  cases,  chronic  in  character,  reported 
by  Hofmeier,  only  one  third  of  the  patients  had  eclampsia,  but  one 
half  died.  Including  acute  and  chronic  cases  together,  Braun  esti- 
mates that  only  sixty  in  the  hundred  develop  uraemic  convulsions. 
Hofmeier  found,  in  five  thousand  births  recorded  upon  the  history- 
books  of  the  Berlin  Clinic,  137  cases  of  nephritis  entered.  Of  these, 
104  patients  only  were  attacked  with  eclampsia.'  Professor  Bamber- 
ger* reports  from  autopsies  of  the  '^^allgemeinen  Krankenhaus"  in 
twelve  years  2,430  cases  of  Bright's  disease,  of  which  152  were  found 
in  puerperal  and  pregnant  women,  viz.,  80  acute  cases,  56  chronic 
cases,  and  IG  cases  of  atrophy  ;  puerperal  eclampsia  was  recorded  in 
23  instances. 

Lohlein  examined  the  records  of  thirty-two  autopsies  made  upon 
eclamptic  women,  and  found  in  eight,  or  in  twenty-five  per  cent,  of  the 
entire  number,  that  dilatation  of  one  or  both  ureters  coexisted  with 
renal  disturbances.  He,  therefore,  pertinently  inquires  how  far  sim- 
ple mechanical  obstruction  of  the  ureters  may  explain  the  apparent 
development  of  uraemic  manifestations  in  certain  cases  without  the 
warning  furnished  by  albumen  in  the  urine. 

*  Bamberger,  "  Ucbcr  Morbus  Brightii  und  seine  Be/Jehungcn  zu  anderen  Krank- 
heitcn,"  Volkraann's  "Sararal.  klin.  Vortr.,"  No.  173,  p.  1541. 


533 


THE  PATHOLOGY  OF  LABOR. 


Finally^  it  is  not  claimed  by  even  the  most  stalwart  champions  of 
the  ursemic  nature  of  eclampsia  that  the  convulsions  which  occur  dur- 
ing pregnancy  and  labor  are  invariably  the  result  of  the  same  cause. 
Thus,  Tyson  says,  There  are  no  reasons  why  we  should  exclude  from 
the  causes  of  the  convulsions  in  the  puerperal  state  those  which  op- 
erate to  produce  convulsions  in  the  non-puerperal  condition."  So- 
called  cases  of  eclampsia  without  albuminuria,  i.  e.,  without  uraemia, 
are  admitted  by  Braun  and  Spiegelberg,  and  referred  by  them  to  reflex 
stimulation  of  the  vaso-motor  and  convulsive  centers  (Krampfcentren). 
They  advocate,  however,  separating  them  off  into  a  class  by  them- 
selves, under  the  title  of  acute  epilepsy,  or  eclamptiform  attacks,  a 
distinction  they  believe  warranted  by  their  rarity  and  their  benign 
behavior.  The  question  of  mere  names,  however,  is  of  small  impor- 
tance. The  main  point  upon  which  it  is  necessary  to  insist  is,  that  it 
is  not  reasonable,  because  in  very  exceptional  cases  uraemia  is  absent  in 
convulsions,  to  deny  to  uraemia,  in  the  overwhelming  proportion  of 
cases  in  which  it  is  demonstrably  present,  its  importance  as  the  most 
distinctive  factor. 

The  objection  drawn  from  the  insignificance  of  the  kidney  changes, 
frequently  observed  in  post-mortem  examinations,  loses  most  of  its 
force  when  we  remember  that  in  a  large  proportion  of  cases  the  reten- 
tion of  excrementitious  materials  is  due  to  acute  suppression.  Thus, 
in  the  104  cases  of  eclampsia  reported  by  Hofmeier,  the  kidney  symp- 
toms developed  suddenly.  This  sudden  suspension  of  the  urinary 
secretion  can  only  result,  Spiegelberg*  argues,  from  disturbances  in 
the  renal  circulation.  A  rapidly  developed  affection  of  the  vessels 
would  leave  no  marked  post-mortem  traces,  and  would,  in  cases  of 
recovery,  disappear  as  quickly  as  it  had  come.  Were  the  kidney 
troubles  due  principally,  as  was  formerly  supposed,  to  pressure  of  the 
gravid  uterus  upon  the  renal  veins,  the  kidneys  should,  in  post-mor- 
tem examinations,  exhibit  evidences  of  congestion,  whereas  usually 
they  are,  on  the  contrary,  found  to  be  pale  and  anaemic.  Besides,  in 
cases  of  pressure  from  ovarian  and  pelvic  tumors  it  is  usually  the 
ureters  and  not  the  veins  which  are  implicated.  The  precise  nature 
of  the  circulatory  changes  is  not,  of  course,  definitely  known.  Spiegel- 
berg suggests  that  either  the  walls  of  the  vessels  are  altered  in  such  a 
manner  as  to  interfere  with  the  process  of  diffusion,  or  that  a  reflex 
contraction  of  the  vessels  due  to  a  peripheral  stimulus  operates  to  cut 
oft'  the  blood-supplies  to  the  kidneys.  Frankenhaeuser,  having  demon- 
strated a  direct  connection  by  means  of  the  sympathetic  nerve  between 
the  ganglia  of  the  kidneys  and  the  nerve-filaments  of  the  uterus,  had 
likewise  suggested  in  effect  that  the  albuminuria  of  pregnancy  was 
due  not  to  pressure  but  to  the  excitation  of  the  uterine  and  renal  nerve 
plexuses. 

*  Spikgelberg,  "Lelirbuch,"  p.  501. 


ECLAMPSIA. 


533 


The  statement  contained  in  the  fifth  proposition  relates  to  a  curi- 
ous fact,  which  has  since  received  confirmation  from  the  pathological 
investigations  of  Cornil  and  Ranvier.  In  a  very  large  proportion  of 
■women  who  had  died  from  uterine  cancer  the  ureters  were  found  oc- 
cluded, with  attendant  dilatation  and  in  some  cases  with  hydrone- 
phrosis. The  histories  of  these  patients  showed  that  in  not  one  in- 
stance had  convulsions  taken  place.  But,  however  remarkable  the  fact 
itself  maybe,  it  is  not  pertinent  to  the  question  of  eclampsia.  Seyfert 
adduced  it  to  prove  that  uraemia  had  nothing  to  do  with  convulsions, 
a  question  which  it  is  hardly  necessary  to  discuss  at  the  present  time. 

A  very  different  interest  attaches  itself,  however,  to  the  inquiry  as 
to  the  causes  of  the  outbreak  of  convulsions.  It  is  well  known  that 
not  every  case  of  nephritis,  or  even  of  kidney  insufficiency,  is  followed 
by  eclampsia,  though  convulsive  attacks  are  much  more  common  in 
the  uraemia  of  pregnant  than  of  non-pregnant  women.  Frerichs  be- 
lieved he  had  found  the  secret  in  supposing  a  ferment  to  develop  in 
the  blood,  which  converted  the  urea  into  carbonate  of  ammonia.  In 
1870  Spiegelberg  reported  an  examination  of  the  blood  of  an  eclamp- 
tic woman  by  the  latest  methods,  and  demonstrated  the  presence 
of  ammonia  in  quantities  sufficient  to  give  color  to  the  supposition 
of  Frerichs  ;  but,  subsequent  investigations  proving  negative,  he  con- 
cluded that  '^ammoniaemia  is  to  be  regarded  as  one  of  the  rarest 
causes  of  convulsions." 

An  apparently  much  more  scientific  explanation  was  afforded  by 
the  now  well-known  Traube-Rosenstein  theory,  which  maintained 
that  eclampsia  took  place  when,  in  persons  rendered  hydraemic  by 
the  loss  of  albumen,  the  aortic  pressure  was  suddenly  increased,  the  in- 
creased pressure  giving  rise  successively  to  oedema  of  the  brain,  then 
to  secondary  compression  of  the  vessels,  and  finally  to  acute  anaemia. 
An  anaemic  condition  of  the  hemispheres  would,  it  was  predicted,  pro- 
duce coma,  while  convulsions  would  ensue  if  the  condition  extended 
to  the  motor  centers. 

The  plausibility  of  this  hypothesis  was  increased  by  the  widespread 
acceptance  of  the  doctrine  taught  by  Andral  and  Gavarret,  that  the 
blood  of  all  pregnant  women  is  hydraemic,  and  by  the  fact  that  the 
existence  of  increased  blood-pressure  during  the  pains  seemed  natural- 
ly to  account  for  the  frequency  of  convulsions  in  labor.  For  a  num- 
ber of  years  after  the  announcement  of  the  Traube-Rosenstein  theory 
it  received  from  me  complete  acceptance  ;  but  my  faith  became  after- 
ward weakened  by  failing  to  find  at  post-mortem  examinations  the 
anticipated  brain-changes,  viz.,  oedema,  anaemia,  and  flattening  of  the 
convolutions.  In  nineteen  examinations,  Lohlein  reported  these  alter- 
ations in  but  a  single  case.  In  his  Lehrbuch  der  Geburtshiilfe " 
Spiegelberg  sums  up  the  objections  in  a  somewhat  contemptuous  fash- 
ion.   First  he  asks  why,  if  the  pathogenetic  symptoms,  as  assumed. 


534 


THE  PATHOLOGY  OF  LABOR. 


are  invariably  present,  eclampsia  is  of  sucli  rare  occurrence,  and  in 
what  way  the  theory  in  question  affords  any  explanation  of  eclampsia 
in  pregnancy  and  childbed  ;  then  he  denies  that  eclamptic  women  are 
for  the  most  part  hydraemic,  that  hydraemia  and  arterial  pressure  are 
capable  of  inducing  cerebral  anaemia,  and  that  the  clinical  evidences 
afforded  by  the  pulse  and  pupils  are  those  produced  by  oedema. 

Angus  Macdonald  reported  in  1878  that  in  the  examination  of  the 
brain  in  eclamptic  persons  he  found  the  meninges  congested  and  the 
venous  sinuses  filled  with  blood,  while  at  the  same  time  there  was 
marked  anaemia  in  the  deeper  layers  of  the  brain-structiire.  The  ven- 
tricles, in  place  of  being  empty,  as  should  have  been  the  case  accord- 
ing to  the  Traube-Eosenstein  theory  of  oedematous  swelling,  were 
found  filled  with  serum.  In  place  of  the  doctrine  of  secondary  com- 
pression, he  expressed  his  belief  that  the  anaemia  resulted  from  arterial 
contraction  due  to  irritation  of  the  vaso-motor  centers  from  excremen- 
titious  principles  retained  in  the  circulation  by  the  insufficiency  of  the 
kidneys. 

The  disposition  to  ascribe  convulsions  to  cerebral  anaemia  is  based 
upon  the  experiments  of  Kussmaul  and  Tenner,  who  demonstrated 
that  convulsive  twitchings  might  be  produced  in  animals  by  tying  the 
carotids  or  by  opening  the  large  vessels  of  the  neck  and  allowing 
them  to  bleed  to  death.  It  is,  of  course,  anticipated  that  anaemia  due 
to  systole  of  the  arterioles  would  be  followed  by  the  same  results.  The 
phenomena  of  convulsions  are  twofold,  viz.,  loss  of  consciousness, 
and  tonic  and  clonic  contractions.  Loss  of  consciousness  is  easily  to 
be  accounted  for  by  anaemia  of  the  hemispheres,  precisely  as  in  cases 
of  ordinary  syncope.  Convulsions  occur,  however,  when  the  brain  is 
removed,  if  only  the  pons  Varolii  and  the  medulla  oblongata  are  pre- 
served. Deiters  has  shown  that  the  motor  fibers  of  the  extremities 
and  the  trunk  have  their  first  central  terminations  in  the  pons.  Noth- 
nagel  *  has  proved  that  a  collection  of  ganglionic  cells  in  the  substance 
of  the  pons  furnishes  the  motor  center  from  which  the  convulsive  im- 
petus takes  its  departure.  According  to  Schroeder  van  der  Kolk, 
the  groups  of  gray  matter  for  the  cranial  nerves  are  situated  in  the 
floor  of  the  fourth  ventricle  and  in  the  substance  of  the  medulla 
oblongata.  A  ay  influence  producing  contractions  of  the  arterioles 
through  the  vaso-motor  nerves  would  necessarily  produce  both  coma 
and  convulsions.  As,  however,  convulsions  may  take  place  without 
loss  of  consciousness,  Nothnagel  concludes  that  the  same  cause  which 
acts  indirectly  through  the  vaso-motor  nerves  may  simultaneously  set 
in  action  the  centers  of  muscular  movements. 

The  foregoing  considerations  justify  the  older  division  of  convul- 
sions into  two  classes,  viz.,  those  due  to  centric  causes,  and  those  pro- 

*  NoTHNAOEL,  "  Ueber  den  epileptischen  Anfall,"  Volkmann's  "  Samml.  klin.  Vortr.,' 
No.  39,  p.  313. 


ECLAMPSIA. 


535 


ceeding  from  peripheral  irritation.  In  both  cerebral  anaemia  plays 
an  important  part.  In  the  oYerwhelming  proportion  of  cases,  uraemia 
is  the  fountain  and  origin  of  the  evil,  the  term  uraemia  signifying,  of 
course,  the  action,  not  of  a  single  constituent  of  the  urine,  but  of  all 
the  excrementitious  principles,  combined  with  that  of  increased  arte- 
rial tension.  Whether,  in  exceptional  cases,  carbonate  of  ammonia  or 
cerebral  oedema  is  present,  is  a  matter  of  slight  moment.  The  role 
played  by  peripheral  irritation  is  not,  however,  to  be  overlooked. 
Without  uraemia,  though  rarely,  peripheral  irritation  can  provoke 
eclampsia.  In  uraemic  cases  the  greater  proportion  develop  during 
labor.  In  Lohlein's  collection,  a  hundred  and  six  in  number,  ninety- 
three  of  the  patients  were  parturient.  Spiegelberg  has  frequently 
seen  convulsions  awakened  in  the  placental  period  by  the  mechanical 
iri'itation  of  the  uterus  during  the  employment  of  the  Crede  method 
of  expression. 

Convulsions  occur  more  commonly  in  primiparae  than  in  multi- 
parae,  especially  in  elderly  primiparae,  in  twin  pregnancies,  and  in 
women  with  contracted  pelves.  They  may  occur  epidemically  in  con- 
sequence of  atmospheric  conditions,  which  probably  interfere  with  the 
functions  of  the  skin  and  thus  indirectly  increase  the  labor  thrown 
upon  the  kidneys. 

Treatment. — The  occasional  examination  of  the  urine  of  pregnant 
women  is  to  be  regarded  as  an  indispensable  precaution.  Faint  traces 
of  albumen  are  not  infrequently  found  in  the  urine  of  women  with 
harmless  catarrhal  affections  of  the  bladder.  Persistent  albuminuria 
calls  for  special  prophylactic  treatment ;  for,  though  convulsions  are 
not  to  be  regarded  as  the  necessary  consequence  of  nephritis,  the  pres- 
ence of  renal  disease  immensely  increases  the  danger  of  sudden  acute 
suppression.  Nephritis  is,  moreover,  apt  to  be  aggravated  by  the 
pregnant  state,  and  Hofmeier  has  shown  that  in  a  considerable  pro- 
portion of  the  cases  which  have  their  origin  in  pregnancy  the  kidney- 
lesions,  contrary  to  the  accepted  belief,  do  not  disappear  spontaneously 
after  parturition.  Every  precaution  should  be  taken,  therefore,  to 
remove  from  albuminuric  patients  all  sources  of  mental  excitement,  to 
ward  off  attacks  of  indigestion,  and  to  defend  them  from  colds.  In 
oedema  of  the  face,  the  extremities,  and  the  labia  majora,  a  strict  milk- 
diet  should  be  enjoined,  and  the  tincture  of  the  chloride  of  iron,  in 
full  doses,  should  be  given  at  least  four  times  a  day,  both  for  its  diu- 
retic and  for  its  haematinic  properties,  and  likewise  to  improve  the 
tonus  of  the  weakened  vessels.  If  the  milk-diet  is  badly  supported  by 
the  patient,  she  should  bo  instructed  to  drink  freely  of  the  natural 
alkaline  waters  possessing  mildly  diuretic  properties,  such  as  the 
Vichy,  the  Selters,  the  Buffalo  lithia-water,  the  Poland  water,  and 
others  of  like  action.  To  remove  the  transuded  serum,  the  skin  should 
be  compelled  to  aid  the  kidneys,  either  by  means  of  the  Turkish  bath 


536 


THE  PATHOLOGY  OF  LABOR. 


or,  where  the  latter  is  not  available,  by  the  wet-pack.  Mild  laxatives, 
such  as  the  Friedrichshall,  the  Hunyadi,  or  the  Saratoga  waters,  are 
useful  in  constipation  of  the  'bowels. 

If  cerebral  symptoms  threaten  the  outbreak  of  convulsions,  the 
nervous  irritability  should  be  held  in  check  by  rectal  injections  of 
chloral  and  the  bromide  of  potassium  (thirty  grains  each),  and  a  hy- 
dragogue  cathartic  should  be  promptly  administered.  Free  catharsis 
unloads  the  blood  of  urea,  diminishes  the  arterial  tension,  and  relaxes 
the  arterioles.  The  immediate  results  are  usually  in  the  highest  de- 
gree satisfactory.  The  pain  in  the  head,  the  sensory  disturbances,  the 
stomach  troubles  disappear,  and  the  patient  becomes  calm  or  sinks 
into  a  gentle  sleep.  Lohlein  recommends  placing  the  woman  in  the 
latero-prone  position,  in  order  to  diminish  as  much  as  possible  the 
pressure  upon  the  ureters  and  upon  the  renal  veins. 

So  far  writers  are  practically  unanimous.  Whatever  differences 
exist  between  them  relate  not  to  principles,  but  to  the  means  best 
adapted  to  accomplish  the  end  in  view.  When,  however,  in  spite  of 
palliative  measures  and  hygienic  precautions,  the  uraemic  symptoms 
have  steadily  progressed  until  the  central  nervous  system  has  become 
involved,  the  question  comes  up  for  decision  whether  to  persevere  in  a 
plan  of  treatment  designed  merely  to  ward  olf  impending  danger,  or 
whether  to  place  the  patient  without  delay  in  a  position  of  relative 
safety  by  the  induction  of  premature  labor.  The  weight  of  authority, 
it  seems  to  me,  is  favorable  to  procrastination,  the  interruption  of 
pregnancy  being  regarded  as  an  extreme  measure,  justifiable  only  in 
cases  of  utmost  peril.  But  premature  labor,  with  the  indications  thus 
limited,  is  not  likely  to  save  many  lives.  My  own  convictions  are 
clear  that,  so  soon  as  grave  cerebral  symptoms  develop,  the  period  of 
folded  hands  has  passed.  The  relief  to  be  obtained  from  chloral  and 
catharsis  is,  as  a  rule,  of  short  duration,  and  we  can  not  go  on  giv- 
ing chloral  and  cathartics  to  the  end  of  gestation,  nor  are  we  sure 
that  the  first  fortunate  results  can  be  reduplicated.  Moreover,  it  is 
necessary  to  take  cognizance  of  the  well-being  of  the  foetus,  which  is 
threatened  by  the  continued  circulation  of  urea  in  the  maternal  blood. 
The  induction  of  premature  labor  by  means  of  the  bougie,  aided,  if 
needful,  by  the  vaginal  douche  and  the  dilating  bags  of  Barnes,  is  at- 
tended with  but  moderate  risk  if  resorted  to  after  the  urgemic  symptoms 
have  been  got  fairly  under  control  ;  if  employed  as  a  last  resource, 
where  other  therapeutical  measures  have  failed,  its  use  is  still  justifi- 
able, though  it  then  partakes  rather  of  the  nature  of  a  forlorn  hope. 

The  indications  for  treatment  during  the  outbreak  are  for  the  most 
part  the  same  as  laid  down  for  uraemic  symptoms  unattended  by  con- 
vulsions, viz.,  to  lower  the  arterial  tension,  to  diminish  to  the  fullest 
extent  practicable  the  irritation  of  the  vaso-motor  and  convulsive  cen- 
ters, and  to  restore  to  the  kidneys  their  normal  functions.  Spiegel- 


ECLAMPSIA. 


537 


barg  claims  that  these  three  indications  are  most  completely  fulfilled  by 
venesection.  A  dozen  years  ago,  at  a  time  when  the  prejudice  against 
*^spoliative  measures"  was  still  strong,  Professor  Fordyce  Barker 
pleaded  for  the  restoration  of  the  lancet  in  the  management  of  puer- 
peral convulsions,  insisting  upon  the  unmistakable  clinical  evidences 
favorable  to  its  employment.  In  my  student-days  in  Paris,  at  the 
Hopital  des  Cliniques,  where  tlie  ancient  usage  was  in  full  favor,  I 
well  remember  my  first  feelings  of  alarm  at  the  vigor  of  the  treatment 
in  vogue  ;  but,  after  carefully  watching  the  cases  to  the  end,  I  was  led 
to  conclude  that  the  claims  of  bleeding  in  eclampsia  rested  upon  a  sub- 
stantial foundation. 

The  special  advantage  of  venesection  lies  in  the  rapidity  of  its  ac- 
tion ;  incidentally  it  favors  absorption  and  renders  the  patient  more 
susceptible  to  the  influence  of  other  remedies.  It  forms,  therefore, 
naturally  the  first  step  in  the  treatment  of  convulsions.  The  quantity 
of  blood  to  be  withdrawn  varies  from  eight  to  sixteen  ounces,  according 
to  the  vigor,  and,  to  some  extent,  according  to  the  size  of  the  individual. 

In  the  May  number  of  the  "  American  Journal  of  Obstetrics,"  1871,  Dr.  H. 
Fearn,  of  Brooklyn,  contributed  an  article  on  "  Veratrum  Viride  in  Large  Doses, 
as  a  Substitute  for  Bloodletting  in  Puerperal  Convulsions,"  in  which  he  recom- 
mended the  tincture  of  veratrum  in  doses  varying  from  fifteen  minims  to  a  tea- 
spoonful,  repeated  every  five  or  ten  minutes  until  the  pulse  became  soft,  or 
vomiting  set  in.  For  several  hours  after  the  convulsions  are  arrested,  he  ad- 
vises the  veratrum  to  be  administered  in  smaller  doses,  in  order  to  keep  the  pulse 
below  fifty  to  the  minute.  He  claims  that  the  large  doses  are  devoid  of  danger 
so  long  as  the  convulsions  continue.  According  to  Kenyon,*  who  has  recently 
contributed  two  cases  successfully  treated  by  veratrum,  "the  drug  is  quickly 
absorbed,  and  enters  the  circulation  rapidly.  IL  enters  the  vasa  vasorum  and 
through  them  impairs  the  sensibility  of  the  vaso-motor  nerves,  the  blood-vessels 
thus  losing  their  tonicity  and  power  of  contraction" — all  good  arguments  for 
its  use  in  convulsions  if  its  safety  can  be  established. 

After  bleeding,  narcotics  and  anaesthetics  should  be  resorted  to,  with 
a  view  of  preventing  the  renewal  of  the  convulsions.  Chloroform  and 
morphia  have  long  been  tested  in  practice,  and  have  sustained  their 
claims  to  professional  favor.  From  one  sixth  to  one  fourth  of  a  grain 
of  morphia  should  be  injected  hypodermically,  the  same  quantity  to 
be  repeated  in  an  hour  in  case  of  the  convulsions  returning.  Chlo- 
roform was  formerly  recommended  in  full  anaesthetic  doses,  so  as  to 
completely  paralyze  the  motor  centers.  As,  however,  experience  has 
shown  that  complete  and  prolonged  anesthesia  is  in  itself  a  source  of 
danger,  it  is  advisable,  except  in  cases  where  labor  is  nearly  at  a  close, 
to  restrict  the  chloroform  to  the  pains,  and  to  the  restlessness  which 
is  often  the  preliminary  of  a  fresh  seizure. 

*  Kentox,  "  Treatment  of  Convulsions  with  Yeratrum  Viride,"  "  N.  Y.  Med.  Jour.," 
October,  1879,  p.  370. 


538 


THE  PATHOLOGY  OF  LABOR. 


The  discovery  of  chloral  has  added  another  invaluable  agent  to  our 
list  of  available  antispasmodics  and  anesthetics.  It  is  my  present 
practice,  after  beginning  with  chloroform,  to  administer  thirty  grains, 
each,  of  chloral  and  bromide  of  potassium  by  the  rectum,  and  to  sus- 
pend the  chloroform  so  soon  as  the  sedative  effects  of  the  latter  agents 
become  developed.  The  frequency  with  which  the  chloral  should  be 
given  depends  upon  the  frequency  and  violence  of  the  attacks.  A 
single  dose  will  sometimes  exercise  a  restraining  influence  for  hours, 
while  in  other  cases  in  the  course  of  an  hour  or  two  the  dose  will  re- 
quire to  be  repeated.  As  a  subsidiary  measure,  with  a  view  to  the 
ultimate  relief  of  the  kidneys,  the  lower  bowel  should  be  cleared  out 
with  an  enema,  and  a  cathartic  (a  drop  of  croton-oil,  or  calomel  and 
jalap  in  case  the  patient  is  able  to  swallow)  should  be  given  by  mouth. 

As  convulsions  which  occur  after  the  advent  of  labor  have  a  ten- 
dency to  recur  so  long  as  the  labor  continues,  and  in  the  larger  propor- 
tion of  cases  cease  after  the  birth  of  the  child,  every  obstetrical  re- 
source compatible  with  the  safety  of  the  mother  should  be  employed  to 
hasten  delivery.  In  the  early  part  of  the  first  stage,  the  pains,  if  slug- 
gish, should  be  stimulated  by  catheterization  of  the  uterus.  Braun 
advocates  rupturing  the  membranes,  as  he  claims  that  the  escape  of 
the  amniotic  fluid  often  diminishes  the  frequency  and  violence  of  the 
convulsions.  The  water-bags  of  Dr.  Barnes,  if  necessary,  should  be 
used  to  promote  the  dilatation  of  the  cervix.  Incisions  through  the 
border  of  the  os  externum  and  accouchement  force  are  unnecessary. 
After  the  first  stage  is  completed,  if  no  mechanical  disproportion  exists 
between  the  head  and  the  pelvis,  a  careful  attempt  to  extract  the  child 
with  forceps  should  be  made.  Every  precaution  should  be  used  to 
avoid  injuring  the  soft  parts.  Obstetrical  aid  is  only  warrantable 
where  it  can  be  employed  without  detriment  to  the  motlier.  In  in- 
strumental cases,  with  the  head  high  in  the  pelvis,  I  have  had  every 
reason  to  feel  satisfied  with  the  Tarnier  forceps,  exchanging  it,  how- 
ever, for  one  of  English  pattern  so  soon  as  the  head  is  brought  to  the 
floor  of  the  pelvis. 

When  convulsions  occur  during  pregnancy,  the  question  as  to  the 
advisability  of  at  once  provoking  labor  is  by  no  means  settled.  The 
material  upon  which  to  form  an  opinion  is  limited,  as  in  niost  cases 
labor-pains  occur  spontaneously  (as  a  consequence  of  the  convulsions). 
Where  medical  treatment  alone  is  pmployed  it  is  certain  that,  in  the 
absence  of  labor-pains,  a  certain  proportion  recover,  and  pregnancy 
may  go  on  to  completion.  On  this  account  it  is  commonly  advised 
not  to  introduce  labor  as  a  complication  into  a  state  of  affairs  already 
sufficiently  dangerous  and  difficult  to  manage.  So  far  as  my  own  ex- 
perience goes,  however,  the  practice  of  waiting  upon  Nature  has  proved 
uniformly  disastrous,  while  the  induction  of  labor  has  furnished  me 
with  a  certain  proportion  of  recoveries.    Braun  declares  he  has  never 


POST-PARTUM  HAEMORRHAGE  AND  RETAINED  PLACENTA.  539 


known  but  one  patient  to  recover  between  the  fourth  and  sixth  months 
of  pregnancy  except  where  abortion  had  taken  place.  The  question  is 
one,  however,  concerning  which  there  exists  a  reasonable  degree  of 
doubt,  and  which  can  not  be  settled  by  the  hap-hazard  experiences  of 
individuals. 

In  the  treatment  of  convulsions  during  the  childbed  period  the 
agents  used  should  be  opium,  chloral,  veratrum,  or  digitalis.  Chloro- 
form and  venesection  should  be  employed  with  extreme  caution,  if, 
indeed,  they  are  ever  entitled  to  confidence  at  that  time. 


CHAPTER  XXXI. 

POST-PARTUM  HEMORRHAGE  AND  RETAINED  PLACENTA. 

Normal  agencies  for  cheeking  hgemorrhage. — Disturbances  of  contractility,  of  retractility, 
of  thrombus  formation. — Treatment. — Method  of  securing  contraction  and  retrac- 
tion.— Treatment  of  cerebral  anaemia. — Retained  placenta. 

The  haemorrhages  which  occur  immediately  after  the  birth  of  the 
child  may  have  their  origin  in  the  uterus,  the  vagina,  or  the  vulva. 
It  is  customary,  however,  to  consider  those  which  spring  from  lacera- 
tions in  a  chapter  by  themselves,  and  to  apply  the  term  post-partum  to 
those  haemorrhages  only  which  arise  from  the  placental  site. 

Unlike  other  grave  complications  of  childbirth,  post-partum  haem- 
orrhage is  not  an  uncommon  event.  It  may  follow  the  simplest  of 
labors,  and,  in  case  of  an  unprepared  physician,  it  may  carry  his  pa- 
tient in  a  few  moments  to  the  brink  of  death.  It  is  impossible  to 
conceive  a  tragedy  more  terrible  than  this.  Occurring,  as  the  accident 
does,  suddenly,  without  Avarning,  in  the  period  of  joy  that  follows  the 
birth  of  a  living  child,  the  sudden  shifting  of  the  scene  becomes  ap- 
palling. If  the  mother  dies  at  such  a  time,  the  luckless  attendant  who 
stands  at  her  bedside,  a  nerveless  spectator,  need  never  expect  forgive- 
ness ;  nor  can  he  shield  himself  behind  the  recorded  ill-successes  of 
others.  Every  competent  accoucheur  knows  in  his  own  heart  that  he 
has  no  right  to  shirk  his  personal  responsibility  in  cases  of  fatal  post- 
partum haemorrhage,  or  to  meanly  throw  the  blame  upon  Providence. 

The  treatment  of  post-partum  haemorrhage  is  one  of  the  most  sat- 
isfactory departments  of  obstetrical  practice.  In  no  other  emergency 
is  the  saving  of  life  so  little  dependent  upon  chance,  and  so  much  upon 
intelligent  human  intervention.  Successful  treatment  is,  however,  less 
the  result  of  a  familiarity  with  the  various  procedures  extolled  by 
writers,  than  of  a  correct  understanding  of  the  mechanism  by  means 
of  which  the  arrest  of  the  haemorrhage  is  to  be  effected. 

Normal  Agencies  for  checking  Hgemorrhage. — In  normal  cases  the 


540 


THE  PATHOLOGY  OF  LABOR. 


flow  which  follows  the  detachment  of  the  placenta  is  of  brief  duration. 
The  torn  arterial  twigs  retract  spontaneously,  the  patulous  mouths  of 
the  veins  become  plugged  with  fibrinous  clots,  while  the  so-called  ve- 
nous sinuses,  which  are  simply  channels  lined  with  endothelium,  with- 
out valves  or  walls,  become  bent,  flattened,  and  obliterated  under  the 
compression  exerted  by  the  muscular  structures  of  the  uterus. 

The  first  requisite  against  haemorrhage  is  the  maintenance  of  firm, 
uniform  contraction  of  the  uterus.  The  contractions,  which  persist 
with  lessened  force  after  the  birth  of  the  child,  during  their  continu- 
ance alone  suffice  to  prevent  haemorrhage  from  the  placental  site.  The 
two  diagrams  borrowed  from  Professor  Breisky  serve  to  illustrate  the 


mechanism  by  which  this  is  effected.  In  the  transition  from  a  to  5, 
the  uterus,  which  shortly  before  harbored  the  entire  ovum,  becomes 
reduced  to  a  body  not  larger  than  the  two  fists.  But  the  duration  of 
the  contractions  is  short,  with  an  ever-increasing  interval  between 
them.  If  their  cessation  were  followed  by  the  return  of  the  uterus 
from  h  to  a,  the  blood  w^ould  once  more  rush  into  the  sinuses,  the 
mouths  of  the  veins  would  open,  the  thrombi  would  be  washed  out  by 
the  pressure  brought  to  bear  upon  them,  and  flooding  would  of  neces- 
sity ensue.  That  this  does  not  take  place  is  owing  to  the  same  force 
which  in  labor  keeps  the  uterus  closed  upon  its  contents  during  the 
descent  of  the  foetus — viz.,  tonic  retraction. 

The  tonic  retraction  of  the  uterus  is  in  part  the  consequence  of 
shortening  of  the  muscular  fibers,  and  in  part  of  their  rearrangement, 
a  thickening  of  the  uterine  walls  resulting  as  the  cell-elements,  in  place 
of  standing  end  to  end,  assume  a  position  more  nearly  parallel  to  one 
another.    Retraction  is  a  permanent  acquisition  of  the  uterus,  and 


Fig.  219. 


POST-PARTUM  HAEMORRHAGE  AND  RETAINED  PLACENTA.  541 


alone  suffices  to  preyent  the  occurrence  of  hasmorrhage.  The  differ- 
ence between  it  and  contraction  is  exhibited  by  the  difference  in  the 
consistence  of  the  post-partuiyi  uterus  during  and  between  the  pains. 
The  contracted  uterus  is  hard  and  firm  like  a  billiard-ball,  while  the 
retracted  organ  is  relatiyely  soft  and  relaxed.  The  two  properties, 
though  distinct,  are  not,  however,  independent  of  one  another.  When- 
ever the  contractions  are  good,  the  retraction  is  well  marked  also. 
Whatever  diminishes  the  contractile  powers  of  the  uterus  is  followed 
by  a  corresponding  falling  off  as  regards  its  retraction. 

In  cases  where  the  muscular  structures  of  the  uterus  fulfill  their 
normal  functions,  the  formation  of  thrombi  is  of  subordinate  impor- 
tance as  a  means  of  arresting  haemorrhage.  Confined  to  the  adherent 
portion  of  the  decidua  serotina,  they  impart  an  uneven  surface  to  the 
placental  site.  Thrombi  which  extend  to  the  intermuscular  veins  are 
pathological.  It  is  only  when  the  uterus  is  flabby,  and  the  muscular 
action  is  in  default,  that  the  thrombi  exercise  any  marked  influence  in 
the  control  of  haemorrhage,  and  even  then  they  bear  so  close  a  relation- 
ship to  puerperal  thrombosis  as  to  approach  dangerously  near  to  the 
confines  of  pathology. 

The  causes  of  post-partiim  haemorrhage  are  to  be  sought  for  in  dis- 
turbances of  the  mechanism  by  which  haemorrhage  is  normally  pre- 
vented. 

Disturbances  of  Contractility. — Contractions  of  the  uterus  may  fail 
from  lowering  of  the  muscular  irritability.  Atony  follows  most  fre- 
quently exhausting  labor,  artificial  deliveries,  rapid  evacuation  of  the 
uterus,  especially  in  multiparae,  where  the  failure  to  contract  has  often 
the  significance  of  a  prolonged  pause-,  excessive  distention  (hydram- 
nios,  twins),  profuse  haemorrhages,  collapse,  nervous  depression,  and 
severe  general  ailments. 

Again,  in  other  cases,  the  functional  disturbance  may  proceed  from 
some  abnormal  condition  of  the  muscular  fiber.  Thus,  the  defects  of 
contractility  may  spring  from  incomplete  development,  as  in  anoma- 
lies of  formation,  in  textural  changes  due  to  some  antecedent  disease 
or  puerperal  condition,  especially  as  to  the  result  of  many  previous 
confinements,  or  finally  from  inflammatory  infiltrations  having  their 
source  in  the  bruising  of  the  lower  uterine  segment  during  labor. 

The  contractions  of  the  uterus  may  be  mechanically  interfered 
with  over  limited  areas  by  retained  portions  of  the  placenta  and  of  the 
membranes,  by  peritoneal  adhesions,  by  tumors  in  the  walls  of  the 
uterus  or  in  the  uterine  appendages,  or  by  a  distended  bladder  or 
rectum. 

Disturbances  of  Retractility. — We  have  already  seen  that  the  tonus 
of  the  muscular  fibers  is  lowered,  and  that  their  rearrangement  is 
incomplete,  whenever  the  uterine  contractions  are  in  default.  At  the 
same  time  the  retraction  of  the  uterus  may  be  directly  hindered  by 


542 


THE  PATHOLOGY  OF  LABOR. 


mechanical  causes,  especially  by  those  which,  like  the  placenta,  the 
membranes,  or  coagula  of  blood,  when  retained  in  the  uterine  cavity, 
prevent,  in  spite  of  continued  contractions,  a  sufficient  closure  of  the 
veins. 

Disturbances  in  Thrombus  Formation. — The  disturbances  which 
interfere  with  the  formation  of  thrombi  occur  for  the  most  part  in 
those  cases  in  which,  owing  to  the  defective  action  of  the  muscular 
structures,  the  blood-stream  arrives  at  the  mouths  of  the  vessels  with 
unchecked  rapidity.  As  a  consequence,  coagulation  does  not  take 
place,  or  the  coagula  are  of  soft  consistence  and  offer  but  feeble  resist- 
ance to  any  sudden  increase  of  blood-pressure,  or  become  mechanically 
detached  by  restless  movements  on  the  part  of  the  patient,  or  by  strain- 
ing with  the  abdominal  muscles. 

Outlying  Causes  of  Post-partum  Haemorrhage.— The  remote  causes 
of  post-partum  haemorrhage — i.  e.,  those  not  immediately  connected 
with  the  uterus — all  act  by  indirectly  interfering  with  either  the  con- 
tractility or  the  tonus  of  the  muscular  fiber,  or  with  the  thrombus  for- 
mation. This  they  do  by  influences  exerted  either  through  the  ner- 
vous system  or  through  the  circulation.  Thus,  the  muscular  irrita- 
bility may  be  impaired  by  general  debility,  by  wasting  diseases,  from 
impoverishment  of  the  blood  due  to  suffering  and  muscular  effort,  from 
psychical  impressions,  and  from  the  external  influences  of  heat  and 
vitiated  air.  The  normal  tonus  of  the  uterine  muscles  may  be  over- 
come, and  the  formation  of  thrombi  disturbed,  by  any  condition  of  the 
circulatory  system  associated  with  increased  pressure  in  the  venous  or 
arterial  trunks.  The  pressure  in  the  uterine  veins  may  be  augmented 
by  the  patient's  getting  up  suddenly  in  bed,  by  acts  such  as  coughing, 
laughing,  sneezing,  vomiting,  and  defecation,  in  which  the  abdominal 
muscles  are  called  into  play,  and  by  all  the  conditions  which  produce 
chronic  congestion  of  the  pelvic  organs.  Increase  of  arterial  tension 
as  a  cause  of  haemorrhage  is  rare.  Breisky  mentions  a  case  where,  in 
a  multipara  without  valvular  heart-disease,  the  cause  of  the  haemor- 
rhage was  apparently  due  to  intense  palpitation  of  the  heart  associated 
with  the  hard,  incompressible  pulse  indicative  of  arterial  fullness.* 

Treatment. — It  is  not  necessary  to  dwell  upon  prophylactic  meas- 
ures. As  has  been  shown  in  the  survey  of  the  causes  of  post-partum 
haemorrhage,  they  comprise  everything  that  has  been  said  concerning 
the  proper  management  of  labor. 

Methods  of  securing  Uterine  Contractions. — It  is  my  own  practice, 
and  one  I  would  urge  upon  others,  to  make  provision  in  the  simplest 

*  The  forcgoinj:;  description  is  little  more  than  a  transcript  of  the  principles  enunci- 
ated in  Broisky's  clinical  lecture,  "  Ucber  die  Behandlung  dcr  puerperalen  Blutungcn," 
(Volkmann's  "  h^amml.  klin.  Vortr.,"  No.  14,  1871).  I  have  found  them  of  the  utmost 
service  to  me  in  practice  durinj^  the  ten  years  past,  and  believe  with  Breisky  that  they 
furnish  the  key  to  successful  prophylaxis  and  treatment. 


POST-PARTUM  HAEMORRHAGE  AND  RETAINED  PLACENTA. 


543 


of  cases  against  tlie  possible  occurrence  of  haemorrhage.  In  the  be- 
ginning of  the  second  stage,  I  examine  my  Davidson  syringe  to  make 
sure  that  the  valves  are  in  good  working  order.  I  then  direct  a  small 
table  to  be  set  by  the  bedside  of  my  patient,  and  place  upon  it  a  bowl 
containing  pieces  of  ice  of  about  the  size  of  a  hen's-egg,  brandy,  sul- 
phuric ether,  neutral  perchloride  of  iron,  carbolic  acid,  ergot,  a  solu- 
tion of  morphia,  and  a  hypodermic  syringe  filled  with  a  fluid  extract 
of  ergot,  using  preferably  a  watery  solution.  Within  easy  reach  I 
likewise  have  placed  a  pitcher  of  hot  water,  another  of  cold  water,  an 
empty  basin  containing  the  Davidson  syringe,  and  a  bed-pan.  All 
this  requires  but  a  few  moments'  time,  and  it  is  of  no  mean  advantage 
to  feel,  in  case  haemorrhage  follows  the  birth  of  the  child,  that  all  the 
appliances  for  prompt  action  are  in  order  and  close  at  hand. 

If  haemorrhage  takes  place,  in  spite  of  the  fact  that  the  uterus  has 
been  carefully  guarded  by  external  pressure  during  the  period  of  de- 
livery, draw  the  pillows  from  under  the  head  of  the  patient,  direct  the 
nurse  to  open  the  windows,  and  inject  the  ergot  in  tlie  hypodermic 
syringe  into  the  outer  surface  of  the  thigh.  Ergot  by  the  mouth  acts 
too  slowly  to  prove  of  service  in  the  face  of  a  great  emergency ;  be- 
sides, in  many  patients  ergot  by  the  mouth  excites  nausea,  and  is  not 
absorbed  by  the  stomach  ;  hypodermically  its  action  is,  as  a  rule, 
rapidly  developed.  Then  introduce  the  hand  into  the  uterus.  If  a 
full  bladder  interferes,  draw  off  the  urine  with  a  catheter. 

The  introduction  of  the  hand  into  the  uterus  I  believe  to  be  a 
matter  of  the  utmost  importance.  When  combined  with  external 
pressure  it  stimulates  the  uterus  to  contract.  The  placenta,  if  ad- 
herent, should  be  detached  with  the  tips  of  the  fingers  ;  if  loose  within 
the  uterine  cavity,  it  should  be  withdrawn  slowly,  taking  care  to  re- 
move the  membranes  entire.  Bits  of  placenta  or  strips  of  membrane 
should  be  carefully  scraped  from  the  uterus,  remembering  that  this  is 
most  easily  effected  during  the  contraction  of  the  organ.  Even  if 
the  placenta  and  membranes  are  expelled  apparently  entire,  it  is  still 
desirable  to  pass  the  hand  into  the  uterus  to  clear  out  clots,  and  to 
make  sure  that  no  part  of  the  ovum  has  been  left  behind.  Once  I  lost 
a  patient  by  neglecting  this  rule.  The  hgemorrhage  was  checked  by 
compression,  and  upon  careful  inspection  of  the  placenta  and  mem- 
branes I  convinced  myself  that  everything  had  come  away.  The 
patient  died  on  the  eighth  day,  of  septicaemia.  The  autopsy  revealed 
the  presence  of  a  small  placenta  succenturiata,  of  the  existence  of 
which,  aside  from  the  haemorrhage,  there  had  not  been  the  slightest 
indication. 

So  soon  as  the  uterus  has  been  emptied  of  everything  capable  of 
preventing  contraction  and  retraction  from  taking  place,  withdraw 
the  hand  into  the  vagina,  and,  with  the  index  and  middle  fingers  in 
the  posterior  cul-de-sac,  press  the  cervix  forward  toward  the  body  of 


544 


THE  PATHOLOGY  OF  LABOR. 


the  uterus.  With  the  external  hand  grasp  the  uterus  through  the 
abdominal  walls,  compress  it  firmly,  and  push  it  downward  toward 
the  pelvis  and  forward  against  the  pubic  bone.  By  this  manoeuvre 
the  cervix  is  closed,  the  uterine  walls  are  brought  into  contact  with 
one  another,  and  contractions  are  stimulated  by  the  direct  irritation 


Fig.  220.— Bimanual  compression  of  uterus.  (Breisky.) 


of  the  large  cervical  ganglion  and  by  the  kneading  of  the  fundus. 
Breisky  states  that  in  many  cases  it  is  possible  to  combine  compression 
of  the  aorta  with  the  foregoing  manipulation. 

If  bimanual  compression  fails  to  speedily  secure  contractions, 
without  removing  the  internal  band  pieces  of  ice  may  be  slipped  into 
the  yagina,  and  thence  pushed  upward  into  the  uterine  cavity.  With 
rare  exceptions,  the  uterus  responds  at  once  to  the  stimulus  of  cold 
applied  to  its  inner  surface.  Should  it  not  do  so,  however,  the  bed- 
pan should  be  placed  under  the  hips,  and  warm  water  of  about  112" 
Fahr.  should  be  injected  into  the  uterus,  care  being  taken  to  expel 
previously  all  air  from  the  tube  of  the  syringe.  The  injection  should 
be  made  slowly  and  without  force,  allowing  the  fluid  to  escape  pari 
passu  with  its  introduction. 

Although,  as  a  precaution,  I  still  keep  within  easy  access  one  of 
the  per-salts  of  iron  as  an  additional  resource  in  case  of  urgent  peril, 
since  the  introduction  of  hot-water  injections  as  a  reflex  exciter  of 
uterine  contractions  I  have  never  found  it  necessary  to  resort  to  their 
use.  This  I  consider  fortunate,  for,  though  there  is  abundant  testi- 
mony as  to  the  efficacy  of  the  per-salts  of  iron  in  post-partum  haemor- 
rhage, the  arrest  of  tlie  flow  appears,  in  some  cases  at  least,  to  have 
been  achieved  at  too  dear  a  price.  Barnes  refers  the  ha3mostatic 
effect  of  the  iron — 1.  To  its  direct  action  in  coagulating  the  blood  in 
the  mouths  of  the  vessels  ;  2.  To  its  action  as  a  powerful  astringent 


POST-PARTUM  HEMORRHAGE  AND  RETAINED  PLACENTA.  545 


on  the  inner  membrane  of  the  uterus,  whereby  the  surface  becomes 
corrugated  and  the  mouths  of  the  vessels  are  constringed  ;  3.  To  the 
fact  that  it  often  provokes  some  amount  of  contractile  action  of  the 
muscular  wall.  Trask,  in  recommending  the  substitution  of  tincture 
of  iodine  for  the  solution  of  the  perchloride  of  iron,  maintains  that  it 
is  the  third  mode  of  action  that  should  be  placed  first  in  the  order  of 
importance.  This  corresponds  with  my  own  experience.  In  two  cases 
where  Monsel's  solution  was  used  the  uterus  contracted  promptly,  and 
the  injection  was  followed  by  no  disturbing  effects.  In  the  third  the 
uterus  remained  large  and  flaccid,  notwithstanding  the  haemorrhage 
was  arrested.  For  two  days  the  patient  did  well ;  on  the  third  the 
lochia  became  excessively  offensive,  the  respirations  stertorous,  and 
the  pupils  dilated  ;  general  paralysis  ensued,  and  death  followed  within 
twenty-four  hours  of  the  attack.  Although  no  autopsy  was  made,  it 
was  clear  to  me  at  the  time  that  the  coagulation  had  followed  the 
vessels  to  the  substance  of  the  uterus,  and  that  the  fatal  result  was  due 
to  the  absorption  of  septic  material  by  the  large,  soft  thrombi,  which, 
by  their  disintegration,  became  the  means  of  conveying  infection  to 
the  remoter  portions  of  the  organism.  Barnes  uses  the  perchloride  of 
iron  after  preliminary  removal  of  the  clots,  in  the  proportion  of  one  of 
iron  to  tliree  of  water.  Most  German  authorities  recommend  the  iron 
in  a  much  more  diluted  form,  and  using  it  in  no  fixed  proportion,  but 
simply  to  pour  the  iron,  following  Seyfert's  prescription,  into  the 
water  until  the  latter  assumes  a  deep  wine-color. 

Engelmann  speaks  enthusiastically  of  swabbing  the  uterus  with 
perchloride  of  iron,  operating  in  the  following  manner  :  I  bring  the 
patient,"  he  says,  in  position  for  forceps,  introduce  a  Cusco's  specu- 
lum, and  with  wads  of  cotton,  prepared  by  an  assistant,  which  I  seize 
by  my  long  dressing-forceps,  I  seek  to  clear  the  cavity  of  the  blood 
which  has  again  accumulated.  The  assistant  has  also  soaked  a  num- 
ber of  cotton  wads,  as  large  as  a  walnut,  in  perchloride  of  iron,  and 
pressed  out  the  mass  of  fluid,  so  as  to  leave  them  well  soaked  but 
merely  moist  with  iron  ;  they  must  be  well  saturated,  but  not  drip- 
ping. So  soon  as  I  have  cleaned  the  cavity  as  far  as  it  is  possible 
amid  the  constant  flow  of  blood,  I  seize  a  wad  of  new  cotton  on  my 
forceps,  and  mop  the  walls  of  the  cavity  thoroughly,  removing  as 
much  as  possible  of  the  clotted  blood  as  I  withdraw  the  cotton.  I 
rapidly  take  up  one  cotton  wad  after  another,  and  swab  the  uterus 
until  tlie  hfemorrhage  ceases.  .  .  .  The  iron  acts  as  a  stimulant  as 
well  as  styptic,  and  the  uterus  speedily  contracts." 

Wallace*  praises  vinegar  as  a  certain  and  safe  remedy  ior post-par- 
tum  haemorrhage:  *'I  pour  a  few  tablespoonfuls  into  a  vessel,"  he 
says,  dip  into  it  some  clean  rag  or  a  clean  pocket-handkerchief.  I 
then  carry  the  saturated  rag  with  my  hand  into  the  cavity  of  the  ute- 

*  "  Trans.  Am.  Gynaecol.  Soc.,''  vol. 

35 


546 


THE  PATHOLOGY  OF  LABOR. 


rus,  and  squeeze  ic ;  the  effect  of  the  vinegar  flowing  over  the  sides  of 
the  cavity  of  the  uterus  and  the  vagina  is  magical.  The  relaxed  and 
flabby  uterine  muscle  instantly  responds.  The  organ  assumes  what  I 
will  term  its  gizzard-like  feel,  shrinking  dcwn  upon  and  compressing 
the  operating  hand,  and  in  the  vast  majority  of  cases  the  hgemorrhage 
ceases  instantly.  Should  one  application  fail  to  secure  sufficient  con- 
traction, the  rag  can  be  withdrawn,  and  a  second  or  even  a  third  can 
be  made,  until  the  uterus  shall  contract  sufficiently  to  stop  the  flow 
of  blood." 

Probably  the  faradaic  current  is  a  most  efficient  agent  in  secur- 
ing contractions  of  the  uterus,  but,  unlike  vinegar  and  hot  water,  a 
battery  is  rarely  on  hand  when  needed.  An  olive-shaped  bulb  elec- 
trode should  be  introduced  into  the  uterus,  and  the  other  pole,  a  flat 
disk,  pressed  upon  the  fundus  ;  or  both  poles  may  be  applied  directly 
over  the  uterus  through  the  abdominal  walls. 

I  have  in  a  number  of  instances  seen  Dr.  I.  E.  Taylor  succeed  in  ; 
instantaneously  causing  the  uterus  to  contract  by  slapping  the  lower 
part  of  the  abdomen  smartly  with  a  wetted  towel.  •  ! 

Compression  of  the  aorta  through  the  abdominal  walls  is  capa-  ! 
ble  of  rendering  temporary  service.  The  method  has  been  objected  to  i 
on  theoretical  grounds  :  first,  because  the  compression  is  brought  to  ' 
bear  equally  upon  the  vena  cava  as  upon  the  aorta ;  and,  second,  be- 
cause  the  pressure  does  not  cut  off  the  blood  which  goes  to  the  uterus 
through  the  aortic  uterine  arteries.  As  a  clinical  fact,  however,  it  is  ; 
indisputable  that  the  pressure  does,  temporarily  at  least,  check  the  (j 
haemorrhage,  a  result  attributed  by  Frankenhaeuser  to  the  simulta-  |j 
neous  stimulation  of  the  aortic  uterine  plexus,  as  that  portion  of  the  * 
sympathetic  nerve  is  termed  which  overlies  the  large  vessels  of  the  i 
trunk  situated  in  the  lumbar  region.  'i 

The  application  of  ice  to  the  abdomen,  or  allowing  a  stream  of 
cold  water  to  fall  from  a  height  upon  the  hypogastrium,  however 
efficacious  they  may  prove  as  means  of  arresting  haemorrhage,  are  open 
to  the  grave  objection  that  they  add  to  already  existing  shock  and  to 
the  prostration  produced  by  the  loss  of  blood. 

Methods  of  securing  Uterine  Retraction.— Uterine  contractions 
afford  only  a  temporary  safeguard  against  haemorrhage.  It  is  uterine 
retraction  that  prevents  recurrence.  At  first  the  hand  furnishes  the 
most  available  means  of  exercising  external  compression.  It  likewise 
possesses  the  advantage  of  being  an  intelligent  instrument,  capable  of 
conveying  to  the  accoucheur  instant  warning  of  any  tendency  to  relax-  j 
ation.  But,  even  after  retraction  is  secured,  its  maintenance  should  r 
not  be  left  to  chance.  Before  leaving  his  patient,  the  physician  should 
provide  some  means  of  subjecting  the  uterus  to  sustained  and  equable 
pressure.  The  usual  method  consists  in  surrounding  the  antevertcd 
organ  with  folded  napkins  or  rolled  stockings,  and  then  applying  a 


POST-PARTUM  HyEMOERHAGE  AND  RETAINED  PLACENTA.  547 


bandage  tightly  to  the  abdomen  to  keep  them  in  position.  Unless 
skillfully  executed,  this  method  accomplishes  little  more  than  to  dis- 
locate the  uterus  laterally.  I  have  been  in  the  habit  of  using  a  round 
bag  of  rubber  covered  with  brown  muslin,  which  I  partially  fill  with 
cold  water,  and  apply  over  the  uterus.  The  dry  cold  is  of  value  as  a 
means  of  exciting  contraction,  while  the  hydrostatic  pressure  is  evenly 
distributed  over  the  fundus  of  the  uterus,  and  helps  to  fix  it  in  the 
median  line.  A  reliable  compress  may  be  improvised  in  any  house- 
hold by  partially  filling  a  sack  with  moistened  sand  or  common  salt. 

Treatment  of  Cerebral  Ansemia. — In  consequence  of  excessive  loss 
of  blood,  the  surface  of  the  body  becomes  blanched,  cold,  and  bedewed 
with  clammy  perspiration  ;  a  feeling  of  muscular  prostration  is  experi- 
enced, with  distress  in  the  prsecordial  region  ;  the  pulse  becomes  small 
and  frequent,  the  respiration  rapid,  and  air-hunger  is  developed  as  the 
result  of  the  deficient  amount  of  oxygen  carried  by  the  attenuated 
blood-stream  to  the  tissues  and  the  medulla  oblongata.  With  these 
general  symptoms  are  associated  special  ones  due  to  disturbances  of 
the  nerve-centers,  as  restless  movements  from  side  to  side,  yawning, 
vomiting,  perversions  of  the  special  senses,  fainting,  and  convulsions. 

Now,  it  is  to  these  latter  symptoms,  indicative  of  intense  cerebral 
anaemia,  and  directly  imperiling  the  life  of  the  patient,  that  treatment 
requires  to  be  addressed.  The  pillows  should  be  withdrawn  from  the 
head,  the  foot  of  the  bed  should  be  raised,  hot  bottles  should  be  placed 
to  the  extremities,  and  warm  cloths  to  the  head  ;  if  syncope  occurs, 
the  abdominal  aorta  should  be  compressed  to  reserve  the  entire  blood- 
mass  for  the  upper  portion  of  the  trunk  and  the  brain  ;  cerebral  con- 
gestion should  be  promoted  by  opiates  (thirty  drops  of  laudanum  by 
the  mouth,  or  ten  minims  of  Magendie's  solution  hypodermically  in- 
jected), and  the  flagging  heart  should  be  stimulated  by  hypodermic 
injections  of  sulphuric  ether,  brandy,  or  whisky.  The  syringe  should 
be  filled  with  the  agent  chosen,  and  the  injection  should  be  made  deep 
into  the  subcutaneous  cellular  tissue  on  the  outer  part  of  the  thigh. 
The  eifect  upon  the  circulation  is  almost  instantly  manifested.  Ex- 
cept in  cases  which  have  passed  beyond  all  possibility  of  recovery,  the 
pulse  reappears  at  the  wrist,  often,  however,  to  fade  away  again  in  a 
few  minutes.  The  stimulant  injections  in  many  cases  require  to  be 
repeated  a  number  of  times  before  the  circulation  becomes  reestab- 
lished. So  long,  however,  as  there  is  a  perceptible  response  to  the 
stimulus,  the  case  is  never  to  be  regarded  as  hopeless. 

Dr.  Gaspar  Griswold  has  employed  successfully  in  a  number  of 
cases,  where  the  heart  had  apparently  beat  for  the  last  time,  intra- 
venous injections  of  ammonia,  using  for  the  purpose  a  five-per-cent. 
solution  (the  officinal  solution  diluted  with  equal  parts  of  water),  and 
injecting  with  a  hypodermic  syringe  from  fifteen  drops  to  a  half- 
drachm  into  one  of  the  superficial  veins  of  the  forearm. 


648 


THE  PATHOLOGY  OF  LABOR. 


In  the  collapse  resulting  from  excessive  haemorrhage,  the  restora- 
tion of  blood  to  the  circulation  by  transfusion  is  theoretically  the 
rational  mode  of  treatment.  In  practice,  however,  the  difficulties  of 
the  technique,  the  hesitation  of  bystanders  to  furnish  the  required 
blood,  combined  with  the  somewhat  unsatisfactory  results  of  transfu- 
sion, are  all  obstacles  to  its  employment.  For  a  long  time  I  carried 
with  me  Aveling's  very  simple  and  ingenious  transfusion  apparatus. 
In  the  few  cases  where  I  had  intended  to  use  it,  however,  the  tubing 
was  never  in  perfect  order.  The  fact  that  in  each  instance  I  suc- 
ceeded eventually  in  rallying  my  patient  by  methods  less  open  to  ob- 
jection has  led  me  at  present  to  omit  it  from  my  list  of  instruments. 
Professor  Gaillard  Thomas  recommends  the  substitution  of  the  intra- 
venous injection  of  milk  for  that  of  blood,  and  reports  cases  illustrat- 
ing its  successful  employment.  The  results  of  his  experiments  he 
sums  up  in  the  following  propositions  : 

1.  The  injection  of  milk  into  the  circulation  in  place  of  blood  is  a 
perfectly  feasible,  safe,  and  legitimate  procedure,  which  enables  us  to 
avoid  most  of  the  difficulties  and  dangers  of  the  latter  oj^eration. 

2.  In  this  procedure,  none  but  milk  removed  from  a  healthy  cow 
within  a  few  minutes  of  the  injection  should  be  employed.  Decom- 
posed milk  is  poisonous,  and  should  no  more  be  used  than  decomposed 
blood. 

3.  A  glass  funnel,  with  a  rubber  tube  attached  to  it,  ending  in  a 
very  small  cannula,  is  better,  safer,  and  more  attainable  than  a  more 
elaborate  apparatus,  which  is  apt,  in  spite  of  all  precautions,  to  admit 
air  to  the  circulation. 

4.  The  intra-venous  injection  of  milk  is  infinitely  easier  than  the 
transfusion  of  blood.  Any  one  at  all  familiar  with  surgical  operations 
may  practice  it  without  fear  of  great  difficulty  or  of  failure. 

5.  The  injection  of  milk,  like  that  of  blood,  is  commonly  followed 
by  a  chill,  and  rapid  and  marked  rise  of  temperature ;  then  all  sub- 
sides, and  great  improvement  shows  itself  in  the  patient's  condition. 

6.  I  would  not  limit  lacteal  injections  to  cases  prostrated  by  haem- 
orrhage, but  would  employ  it  in  disorders  which  greatly  depreciate 
the  blood,  as  Asiatic  cholera,  pernicious  anaemia,  typhoid  fever,  etc., 
and  as  a  substitute  for  diseased  blood  in  certain  affections  which  im- 
mediately call  for  the  free  use  of  the  lancet,  as  puerperal  convulsions, 
etc. 

7.  Not  more  than  eight  ounces  of  milk  should  be  injected  at  one 
operation. 

After  the  heart's  action  has  once  been  established,  the  efforts  of 
the  physician  should  next  be  directed  to  the  filling  of  the  emptied 
vessels.  Even  when  the  injections  of  milk  or  blood  have  been  resort- 
ed to,  the  quantity  of  fluid  introduced  into  the  circulation  is  too  small 
to  restore  the  arterial  tension.  But,  with  the  restoration  of  the  cardiac 


POST-PARTUM  HEMORRHAGE  AND  RETAINED  PLACENTA.  549 


pulsations,  the  absorption  from  the  stomach  is  very  active  and  rapid. 
To  avoid  vomiting,  however,  it  is  necessary  that  fluids  administered 
by  the  mouth  should  be  given  in  small  quantities  and  at  brief  inter- 
vals. I  usually  begin  with  either  hot  strong  tea,  without  milk,  or 
with  brandy-and- water  (1  :  2),  at  first  a  teaspoonful  at  a  time,  repeat- 
ing  the  quantity  every  minute,  then  giving  a  tablespoonful  of  any 
warm  liquid  every  five  minutes,  carefully  testing  the  capacity  of  the 
stomach  to  dispose  of  its  contents,  withholding  everything  with  the 
first  premonition  of  nausea,  until  milk,  broths,  tea,  gruel,  and  the  like 
are  found  to  be  tolerated  in  ordinary  quantities.  Fluid  nourishment 
should  be  continued  hourly,  with  ice  and  water  in  the  intervals,  ac- 
cording to  the  thirst  experienced,  until  the  radial  pulse  is  restored  to 
its  normal  fullness.  For  the  successful  management  of  these  cases  it 
is  necessary  that  the  physician  assume  the  entire  charge.  It  is  not 
possible  to  give  directions  to  a  nurse  which  may  not  at  any  moment 
require  modification. 

In  cases  of  excessive  loss  of  blood  a  tourniquet  to  each  femoral  ar- 
tery, a  roller  bandage,  or,  better  still,  an  Esmarch  bandage  aj)plied 
the  length  of  the  lower  extremities,  may  be  temporarily  employed 
with  a  view  to  saving  the  limited  amount  of  blood  in  the  circulation 
for  the  important  organs  of  the  trunk  and  for  the  nerve-centers. 

Where  the  pulse  is  extremely  rapid,  the  subcutaneous  injection  of 
one  fiftieth  of  a  grain  of  digitalin  is  reported  to  act  favorably  by  caus- 
ing contractions  of  the  arterioles  and  of  the  uterus. 

Opiates  should  be  administered  from  time  to  time  during  convales- 
cence, the  frequency  and  quantity  depending  wpon  the  intensity  of 
the  headache  which  acute  anaemia  induces. 

The  Puerperal  Haemorrhages. — Haemorrhages  occurring  after  the 
first  day  following  confinement  are  the  result  either  of  the  separation 
of  the  thrombi  from  the  placental  site  or  of  a  congested  condition  of 
the  endometrium. 

Before  the  consolidation  of  the  thrombi  is  completed,  the  mouths  of 
single  vessels  may  be  opened  by  any  sudden  increase  of  pressure  in  the 
uterine  vessels.  A  relaxed  state  of  the  uterus,  obstacles  to  retraction, 
fecal  accumulations,  and  malpositions  of  the  uterus  predispose  to  the 
occurrence  of  haemorrhage.  Common  causes  of  late  haemorrhages  are 
sitting  up  or  leaving  the  bed  at  too  early  a  period,  exertions  in  caring 
for  the  infant,  and  straining  at  stool.  In  the  case  of  a  small,  thin 
woman,  who  flowed  profusely  in  the  second  week,  I  found  the  uterus 
crowded  backward  and  downward  to  the  pelvic  floor  by  the  compress, 
which  had  been  too  tightly  bandaged  upon  the  abdomen  by  the  indis- 
creet zeal  of  the  nurse. 

Where  portions  of  the  ovum  have  been  allowed  to  remain  behind 
in  the  uterus,  they  may  lead  to  the  formation  of  fibrinous  polypi, 
which,  as  in  the  non-puerperal  uterus,  may  lead  to  a  vascular  condi- 


550 


TEE  PATHOLOGY  OF  LALOR. 


tion  of  the  mucous  membrane,  and  become  the  cause  of  protracted 
bleeding. 

The  treatment  of  late  haemorrhages  consists  in  rest  in  the  horizon- 
tal position,  in  carefully  regulated  diet,  in  emptying  both  bladder  and 
rectum,  in  the  correction  of  displacements,  and  in  the  use  of  hot  vagi- 
nal injections.  In  excessive  ante  version  a  compress  above  the  pubes 
is  indicated ;  in  retro-displacements,  lifting  the  uterus  into  position, 
maintaining  it  in  place  by  a  suitable  pessary,  is  often  at  once  fol- 
lowed by  relief.  If  other  causes  can  be  excluded,  the  uterine  cavity 
should  be  explored,  and  retained  bodies,  if  found  present,  should  be 
removed.  When  the  cervix  is  patulous  this  can  be  accomplished  by 
the  finger ;  if  the  cervix  is  closed,  or  if  inflammation  be  present,  the 
wire-curette  can  be  used,  as  after  abortion,  without  preliminary  dilata- 
tion. In  curetting  the  uterus  the  operator  should  be  mindful  of  the 
delicacy  of  the  newly  forming  mucous  membrane,  and  should  feel 
carefully  for  the  offending  bodies.  If  intra-uterine  injections  are  fur- 
ther needed  to  arrest  bleeding,  the  preference  should  be  accorded  to  ■ 
the  tincture  of  iodine. 

Retained  Placenta. 

Retained  placenta  is  so  frequent  a  cause  of  hindered  uterine  re-  ' 
traction  that  a  few  words  concerning  the  etiology  and  treatment  of 
the  condition  form  an  appropriate  appendix  to  the  discussion  of  post- 
partum haemorrhage. 

Cases  of  so-called  placental  retention  are  often  simply  the  result  of  ' 
injudicious  management.   Thus,  they  may  be  caused  by  pulling  in  such 
a  way  upon  the  cord  as  to  draw  the  center  of  the  placenta  into  the  cer- 
vix, so  that,  without  allowing  air  to  pass  by  the  placenta  to  the  uterine  ; 
cavity,  extraction  is  rendered  impossible  ;  or,  when  Crede's  method  is 
practiced,  the  operator  may,  by  pressing  the  fundus  forward  against  ' 
the  pubes  instead  of  downward  in  the  axis  of  the  pelvis,  produce  an 
acute  anteflexion,  with  stenosis  of  the  lower  uterine  canal. 

True  retention  may  be  due  to  the  large  size  of  the  placenta  or  to 
pathological  adhesions,  either  of  the  placenta  itself  or  of  the  chorion. 

An  adherent  placenta  is  of  rare  occurrence,  and  can  usually  be 
traced  to  a  bygone  endometritis.  Separation  normally  takes  place  in 
the  areolar  layer.  If  the  glandular  walls  which  constitute  the  septa 
of  the  areolae  consist  of  tough  intercellular  substance,  instead  of  soft 
tissue  abundantly  supplied  with  cells,  the  separation  does  not  take  i 
place  and  the  placenta  remains  adherent.  The  thick  bands  which  ' 
have  to  be  severed  in  removing  the  placenta  are  in  general  the  straight 
trunks  of  the  villi,  which  run  from  the  chorion  to  the  serotina,  the 
separation  taking  place  not  in  the  decidual  but  in  the  fetal  layer.  In 
placentitis  the  bands  consist  of  thickened  decidual  tissue  extending 
between  the  cotyledons.    In  either  case  the  serotina  is  left  nearly  or 


POST-PARTUM  HEMORRHAGE  AND  RETAINED  PLACENTA.  551 


quite  entire  ;  in  some  instances,  owing  to  their  firm  attachment,  whole 
lobules  may  be  left  behind. 

Adhesions  of  the  chorion  may  be  due  to  thickening  of  the  septa  in 
the  areolar  layer ;  to  defective  involution  of  the  cell-layer  of  the  de- 
cidua,  thickened  portions  of  which  in  consequence  remain  attached  to 
the  separated  chorion  ;  to  secondary  adhesions  from  consolidated  masses 
of  fibrine,  the  remains  of  apoplectic  effusions  into  the  decidua  ;  and, 
perhaps,  to  excessive  development  of  villi  upon  portions  of  the  smooth 
chorion,  from  which  proceed  thick  bands  which  are  firmly  united  to 
the  decidua  (Spiegelberg).  Adhesions  of  the  chorion  interfere  with 
the  separation  of  the  placenta  only  when  situated  high  up  or  around 
the  placental  border. 

The  Artificial  Separation  of  the  Placenta. — Whenever  compression 
of  the  uterus  proves  unavailing  to  procure  the  expulsion  of  the  pla- 
centa, the  operator  should  seek  to  aid  the  delivery  by  the  resources  of 
art.  To  leave  the  placenta  within  the  uterus  not  only  exposes  the 
patient  to  the  risks  of  haemorrhage,  but  to  the  even  greater  danger  of 
decomposition  and  of  septic  poisoning.  A  digital  examination  will 
indicate  the  proper  course  to  be  pursued.  If  the  placenta  be  found 
covering  the  os,  a  finger  should  be  introduced  to  bring  down  a  placen- 
tal border.  If  no  adhesions  exist,  moderate  tractions  upon  the  cord 
will  then  suffice  to  deliver  the  placenta.  Spiegelberg  recommends 
using  the  vaginal  finger  as  a  pulley  to  cause  the  tractions  upon  the 
placenta  to  be  made  in  a  vertical  direction. 

If  tractions  upon  the  cord  are  insufficient,  or  if  the  cord  begins  to 
tear,  the  outer  hand  should  make  counter-pressure  upon  the  fundus, 
while  the  fingers  of  the  vaginal  hand  are  passed  upward  into  the  uter- 
ine cavity.  At  first  a  point  should  be  selected  where  the  placenta  is 
already  partially  detached,  and  the  fingers  should  be  employed  to  roll 
the  placenta  away  from  the  uterine  wall.  If  the  attachment  of  the 
placenta  is  firm,  the  fingers  should  be  extended  with  the  back  of  the 
hand  to  the  uterus,  and  the  separation  attempted  by  a  side-to-side 
movement,  as  in  cutting  the  leaves  of  a  book.  Contractions  are  here 
of  great  service,  as  they  both  facilitate  the  separation  and  serve  to  ren- 
der distinct  the  border-line  between  the  placenta  and  the  uterus. 
Hildebrandt  advises  following  the  cord  upward  and  separating  the 
placenta  with  the  hand  covered  by  the  membranes,  as  a  means  of 
avoiding  the  dangers  of  infection  and  of  injuring  the  internal  uterine 
surface.  Spiegelberg  says  that  in  his  experience  this  method  has 
succeeded  only  where  the  placental  attachment  was  loose  and  the 
separation  easy. 

Bands  should  be  divided  by  pressing  them  between  the  thumb-nail 
and  the  index-finger.  When  the  placenta  is  situated  upon  the  anterior 
wall,  the  patient  should  be  placed  upon  the  side.  When  the  placenta 
is  everywhere  adherent,  a  thickened  border  should  be  chosen  as  the 


552 


THE  PATHOLOGY  OF  LABOR. 


point  for  commencing  the  detachment.  In  a  very  thin,  diffused  pla- 
centa, it  has  been  proposed  by  Hohl  to  inject  the  vessels  through  the 
umbilical  vein. 

The  operation  of  separating  the  placenta  should  never  be  performed 
hurriedly.  Every  pains  should  be  taken  to  avoid  injuring  the  uterine 
surface,  and  as  little  placental  tissue  as  possible  should  be  left  behind. 

When  the  detachment  of  the  placenta  is  completed,  it  should  be 
grasped  from  above,  in  the  full  hand,  and  its  expulsion  should  be 
effected  by  external  pressure.  If  portions  of  the  membranes  are  torn 
away  during  delivery,  they  should  be  sought  for  and  carefully  re- 
moved. 

In  every  case  of  artificial  placental  delivery  the  cavity  of  the  uterus 
should  subsequently  be  thoroughly  irrigated  with  warm  carbolized 
water. 


CHAPTER  XXXII.  ; 

PLACENTA  PREVIA.— ACCIDENTAL  HAEMORRHAGE.— INVEBQION  OF 

THE  UTERUS.  < 

( 

Situation. — Varieties. — Frequency. — Causes  of  haemorrhage. — Clinical  features. — Prog-  ! 
nosis. — Diagnosis  — Treatment. — Accidental  heemorrhage. — Inversion  of  the  uterus. 

Situation. — Normally  the  placenta,  as  we  know,  is  situated  at  the 
fundus  and  upon  the  side-walls  of  the  uterus.  It  is  said  to  be  prcBvia  ' 
when  it  occupies  that  portion  of  the  uterus  which  is  subject  to  disten-  ; 
tion  during  labor,  or,  in  other  words,  to  the  spherical  surface  of  the  i 
lower  portion  of  the  uterus.  Its  clinical  importance  is  proportioned  j 
to  the  extent  of  the  placental  segment  which  overlaps  the  os  internum.  \ 
Hence  it  is  customary  to  distinguish — 

Varieties. — 1.  Placenta  prmvia  centralis,  where,  after  the  dilata- 
tion of  the  OS  internum  has  become  complete,  the  placenta  only  can 
be  felt. 

2.  Placenta  prcevia  partialis,  where,  with  dilated  os,  there  is 
recognizable  a  portion  of  the  membranes,  as  well  as  a  segment  of  the 
placenta. 

3.  Placenta  prcBvia  lateralis,  or  marginalis,  where  the  placental 
border  stretches  down  to  but  not  beyond  the  margin  of  the  inner  cer- 
vical ring. 

Observations  which  tend  to  prove  the  attachment  of  the  placenta 
in  part  to  the  cervical  mucous  membrane  are  unquestionably  errone- 
ous. This  fact,  first  stubbornly  insisted  upon  by  Professor  I.  E.  Tay- 
lor, has,  at  least  among  physiologists,  passed  beyond  the  realm  of 
dispute.  Kuhn,*  who  investigated  the  subject  in  conjunction  with 
*  BuAUN,  "  Lchrbuch  der  ges.  Gynaek.,"  p.  555. 


PLACENTA  PREVIA. 


553 


Carl  Braiin,  found  that  in  no  case  was  the  placental  portion  which 
occupied  the  cervical  canal  adherent  to  the  canal- walls,  but  that  in 
all  post-mortem  examinations  the  remains  of  tlie  placenta  praevia  ma- 
terna  ended  by  a  sharp  border-line  at  the  os  internum. 

An  exact  central  implantation  of  the  placenta  is  extremely  rare, 
though  its  occurrence  is  not  impossible.  Usually  in  the  so-called 
central  form  not  more  than  one  sixth  to  one  fourth  of  the  placental 
surface  overlaps  the  os  internum.  The  smaller  segment  is  oftener 
found  upon  the  left  side  (37  :  56,  statistics  of  L.  Miiller).* 

Owing  to  the  deficient  thickness  of  the  decidua  in  the  vicinity  of 
the  internal  os,  the  placental  villi  grow  with  less  profusion  at  that 
point,  while  by  way  of  compensation  in  more  favored  localities  they 
attain  to  an  excessive  development.  The  placenta  thus  assumes  a 
characteristic  uneven  appearance.  If  the  atrophic  conditions  exist 
over  a  wide  extent,  the  surface  of  the  placenta  is,  as  a  rule,  corre- 
spondingly increased. 

Another  peculiarity  not  devoid  of  practical  interest  is  the  fre- 
quency with  which  the  placenta  is  found  adherent  to  the  uterine  walls. 
Of  142  cases,  L.  Miiller  showed  that  in  56  adhesions  existed.  The 
insertion  of  the  cord  into  the  placenta  is  usually  eccentric,  often  mar- 
ginal, and  sometimes  velamentous.  As  a  consequence,  prolapsed  funis 
is  a  common  accompaniment  of  the  anomaly. 

Fortunately,  placenta  praevia  is  of  rare  occurrence.  Muller,  by 
adding  together  the  statistics  of  various  investigators,  found  reported 
813  instances  in  876,432  births,  or  not  quite  one  case  in  a  thousand. 

Etiology. — The  causes  are  unknown.  The  proportion  of  multi- 
parae  to  primiparae  is  very  large  (6  :  l).f  Placenta  praBvia  is  most  fre- 
quent in  women  who  have  borne  children  with  great  rapidity,  and  in 
pregnancies  shortly  following  abortions,  conditions  which  favor  relax- 
ation of  the  uterine  walls,  dilatation  of  the  cavity,  and  defective 
development  of  the  decidua.  Miiller  advances  the  theory  that  the 
descent  of  the  ovum  is  effected  by  contractions  of  the  uterus  soon 
after  conception.  Such  expulsive  pains  naturally  lead  to  abortion. 
In  certain  cases,  however,  where  the  reflexa  is  absent,  we  have  seen 
that  the  ovum  may  be  forced  downward  into  the  cervical  canal,  and 
lingering  there  may  give  rise  to  '^cervical  pregnancy."  Placenta 
praevia  Miiller  believes  to  be  due  to  an  abortion  begun  at  an  early 
period,  but  arrested  at  the  lower  uterine  segment  to  which  the  villi 
attach  themselves,  and  enable  the  rescued  ovum  to  continue  its  devel- 

*  LuDWiG  MuLLEn,  "Placenta  Pravia,"  Stuttgart,  ISYT.  Most  of  my  statistics  arc 
taken  from  this  work.  They  include  those  of  Trask  ("  Am.  Jour,  of  the  Med.  Sci.," 
1856,  vol.  viii)  and  of  most  of  the  later  writers,  up  to  date  of  publication. 

f  Muller  collected  from  different  reporters  1,5'74  cases — 227  of  primiparae  and  1,347 
of  multiparae.  JiidcU  reports  the  multiparas  at  90  per  cent.  King  ('"Am.  Jour,  of 
Obstet.,"  October,  1880,  p.  751)  reports  183  cases  collected  in  the  State  of  Indiana,  in 
which  the  proportion  was  20  primiparae  to  163  multiparas. 


554 


THE  PATHOLOGY  OF  LABOR. 


opment.  Ingleby  relates  two  curious  cases  where  the  orifices  of  the 
Fallopian  tubes  opened  near  the  os  internum,  in  one  of  which  placenta 
praevia  occurred  three  times,  and  in  the  other  ten  times. 

Clinical  Features. — The  chief  clinical  importance  of  placenta  prse- 
via  results  from  the  mode  of  its  detachment  during  labor.  In  normal 
positions,  the  separation  of  the  placenta  is  eifected  by  virtue  of  the 
uterine  contractions  after  the  foetus  has  for  the  most  part  been  ex- 
pelled. In  placenta  praevia  the  separation  is  due  to  the  stretching  to 
which  the  lower  uterine  zone  is  subjected  in  its  conversion  from  a  half- 
sphere  to  a  cylindrical  canal  to  permit  the  passage  of  the  child.  The 

extent  of  unavoidable  separation  in  ad- 
vance of  delivery  is  consequently  meas- 
ured by  the  dimensions  of  the  child's 
head,  the  largest  circumference  of 
which  is  estimated  as  equivalent  to  a 
circle  with  a  diameter  of  four  and  a 
half  inches.  According  to  Duncan, 
the  plane  at  which  spontaneous  detach- 
ment ceases  is  reached  at  a  distance  of 
two  and  a  half  inches  by  following  the 
curve  of  the  lower  segment,  and  of  one 
inch  and  a  half  if  measured  in  the  di- 
rection of  the  uterine  axis.  Whereas, 
in  normal  labor,  the  contractions  of  the 
uterus  which  determine  placental  sepa- 
ration close  at  the  same  time  the  ori- 
fices of  the  torn  vessels,  the  stretching 
of  the  lower  segment  in  placenta  pras- 
via  leaves  the  mouths  of  the  sinuses 
gaping,  from  which  the  blood  pours 
until  the  stream  is  arrested  either  by 
art  or  by  the  supervention  of  syncope. 
As  the  haemorrhage  in  such  cases  is  the  natural  s'equence  of  cervical 
dilatation,  its  occurrence  during  labor  was  termed  byKigby  ^^unavoid- 
able" in  contradistinction  to  haemorrhages  from  detachment  of  the 
placenta  when  situated  near  the  fundus,  where  the  sejiaration  is  attrib- 
utable to    accidental "  causes. 

The  haemorrhages  of  placenta  praevia  are  not,  however,  limited  to 
the  parturient  period.  Indeed,  there  is  no  time  in  pregnancy  when 
they  may  not  occur.  When  we  consider  that  every  jar  of  the  body 
affects  the  lower  segment  with  more  force  than  the  fundus,  and  that 
the  thinned  walls  of  the  utero-placental  vessels  are  subject  to  increased 
pressure  in  placental  presentations,  it  becomes  evident  that  a  very 
slight  occasion  is  sufficient  to  produce  rupture  and  haemorrhage. 
Thus  placenta  i^raevia  is  a  common  cause  of  the  pseudo-menstruation 


Fig.  221. — DiaOTam  showingr  the  una- 
voidable placental  separation  as  a 
consequence  of  cervical  dilatation. 


PLACENTA  PREVIA. 


555 


of  pregnancy ;  it  creates  a  predisposition  to  abortion,  and,  later  in 
gestation,  to  premature  labor,  the  haemorrhages  being  due  probably  in 
the  first  instance  to  accidental  causes  and  not  to  labor-pains.  Not 
every  case  of  haemoi'rhage  is,  however,  followed  by  labor.  Indeed,  in 
many  instances  thrombi  form  in  the  open  vessels,  the  bleeding  be- 
comes arrested,  and  pregnancy  goes  on  for  a  time  undisturbed.  The 
tables  of  Miiller  show  that  in  complete  placenta  prsevia  the  first 
haemorrhage  occurs  with  the  greatest  frequency  between  the  twenty- 
eighth  and  thirty-sixth  weeks,  while  in  the  incomplete  form  it  takes 
place  most  commonly  after  the  thirty-second  week.  In  placenta 
praevia  lateralis,  haemorrhages  are  sometimes  absent  up  to  the  time  of 
labor.  Cases  of  pregnancy,  and  in  part  of  labor,  without  haemorrhage 
have  been  observed  where  the  death  of  the  foetus  has  been  followed  by 
atrophic  changes  in  the  placenta.  The  recurrence  of  haemorrhage  is 
oftentimes  prevented  by  secondary  shrinkage  of  the  placenta,  due  to 
pressure  from  the  efiused  blood  or  to  thrombosis  of  the  vessels  which 
supply  the  implicated  cotyledons. 

The  haemorrhages  of  placenta  praevia  are  usually  sudden,  without 
premonitory  warnings,  without  pain,  often  without  any  apparent  occa- 
sion, sometimes  occurring  at  the  time  of  urination,  sometimes  during 
sleep.  The  quantity  of  blood  lost  in  a  single  haemorrhage  depends 
upon  the  extent  of  the  placental  separation.  The  first  outpouring  may 
lead  to  intense  anaemia,  and  if  repeated  at  a  short  interval  may  cause 
death.  It  is  estimated  that  from  one  to  three  pounds  of  blood  may  be 
lost  in  a  single  attack,  and  from  four  to  five  pounds  in  the  course  of 
labor  (Miiller).  As  a  rule,  however,  the  haemorrhages  of  pregnan- 
cy are  at  first  moderate  in  character,  increasing  in  violence  with 
each  repetition.  A  very  formidable  variety  is  the  so-called  ^'stillicid- 
ium,"  where  the  blood  issues  drop  by  drop  for  days  and  even  weeks 
in  succession.  The  most  violent  haemorrhages  occur  generally  in  the 
earlier  part  of  the  first  stage  of  labor.  As  a  rule,  the  extent  of  the 
haemorrhage  is  proportioned  to  the  area  of  the  placental  segment 
attached  to  the  uterine  surface  subject  to  distention.  The  haemor- 
rhage generally  ceases  when  the  separation  of  the  cotyledons  is  com- 
pleted and,  after  the  rupture  of  the  membranes,  the  pressure  of  the 
presenting  part  is  brought  to  bear  upon  the  bleeding  surface.  Dur- 
ing the  height  of  the  pains,  too,  the  haemorrhage  is  for  the  moment 
arrested  (Spiegelberg).* 

The  number  of  abnormal  presentations  in  placenta  praevia  is  very 
large.  Thus,  in  Miiller's  statistics,  in  1,148  cases  there  were  372  trans- 
verse and  107  breech  presentations.  The  frequency  of  the  anomalies 
is  partly  attributable  to  the  large  proportion  of  premature  labors,  and 

*  This  view  was  first  advanced  by  Fountain  in  the  "  Am.  Jour,  of  the  Med.  Sei."  It 
has  since  been  advocated  by  Duncan,  Judell,  Frankel,  Spiegelberg,  and  others.  MUller 
and  Kuhn,  however,  dispute  it,  as  justified  neither  by  theory  nor  by  observation. 


556 


THE  PATHOLOGY  OF  LABOR. 


partly  to  the  width  and  lax  condition  of  the  lower  segment,  and  the 
consequent  want  of  stability  in  the  foetus. 

During  the  first  stage  of  labor  the  pains  are  apt  to  be  feeble  and 
the  dilatation  tardy.  The  causes  of  inertia  are  to  be  found  in  the 
thinning  of  the  muscular  structures  in  the  lower  segment  from  the 
enormous  development  of  the  utero-placental  vessels ;  in  the  attach- 
ment of  the  placenta  over  the  os,  which  mechanically  hinders  dilata- 
tion ;  and  in  the  fact  that  the  ovum  does  not  press  directly  upon  the 
sensitive  nerves  of  the  cervix.  Secondary  weakness  often  follows  the 
continued  losses  of  blood  and  the  prolongation  of  the  first  stage. 
When  the  obstacle  afforded  by  the  placenta  to  dilatation  has  been 
overcome,  and,  consecutive  to  rupture  of  the  membranes,  the  uterus 
retracts,  in  many  cases  the  scene  speedily  changes,  and,  in  place  of 
ineffective  contractions,  normal  and  often  powerful  pains  develop. 

As  a  rule,  quite  early  in  labor  the  cervix  is  found  soft  and  dilat- 
able, but  to  this  rule  there  are  numerous  exceptions.  Strictures  and 
rigidity  Miiller  computes  to  exist  in  about  twelve  per  cent,  of  the 
cases. 

Where  the  loss  of  blood  in  labor  is  continuous  the  woman  grows 
restless  and  complains  of  headache  and  vertigo  ;  the  respirations  be- 
come short,  interrupted,  and  sighing,  and  the  pulse  small,  weak,  and 
thready.  Toward  the  close  unconsciousness  develops,  the  brow  is  be- 
dewed with  cold,  clammy  perspiration,  and  finally  convulsions  usher 
in  the  fatal  termination. 

Even  after  labor  is  over  the  danger  is  not  ended.  Post-partum 
haemorrhage  may  result  from  atony  of  the  placental  surface  of  the 
uterus,  or,  after  good  contractions  have  been  apparently  secured,  sud- 
den relaxation  may  follow,  and  the  blood  pour  out  in  a  torrent,  so 
that  the  patient  becomes  a  corpse  before  assistance  can  be  rendered. 
Again,  in  childbed  the  imperfect  contraction  of  the  uterus  at  times 
allows  the  lochia  to  form  a  stagnant  pool  at  the  fundus,  whence  an 
ichorous  discharge  flows  constantly  downward  over  the  thinned  walls 
and  open  mouths  of  the  vessels  at  the  placental  wound.  The  feeble 
circulation  predisposes  to  the  formation  of  thrombi,  which,  when 
poisoned  and  disintegrated,  are  conveyed  into  the  general  circulation 
and  give  rise  to  the  dreaded  symptoms  of  pyaemia.  Miiller  found  in 
two  hundred  and  seventy-three  of  his  cases  specific  information  given 
regarding  the  puerperal  state.  ^'Puerperal  fever"  was  recorded  of 
seventy-nine  patients,  with  fifty-four  deaths. 

Prognosis. — The  prognosis  of  placenta  praevia  is  necessarily  ex- 
tremely unfavorable.  As  many  as  one  mother  in  four  dies  during 
or  shortly  after  delivery.  Including  deaths  from  puerperal  processes, 
Miiller  estimates  the  total  mortality  at  not  less  than  from  thirty-six  to 
forty  per  cent.  Nearly  two  out  of  three  of  the  children  are  born  dead. 
More  til  an  one  half  of  those  born  living  die  within  the  first  ten  days. 


PLACENTA  PREVIA. 


557 


In  general  terms  it  may  be  stated  that  the  prognosis  is  the  more  seri- 
ous, the  earlier  the  haemorrhages  begin  in  pregnancy,  the  more  pro- 
fuse the  flow,  and  the  shorter  the  intervals  between  the  attacks.  Dur- 
ing labor  favorable  conditions  are  a  vertex  presentation,  good  pains, 
rapid  dilatation,  and  an  unbroken  constitution.  The  maternal  mor- 
tality is  twice  as  great  in  placenta  praevia  centralis  as  in  placenta  prae- 
via  lateralis.  In  the  city,  there  is  the  special  danger  of  infection  ;  in 
the  country,  of  delay  in  obtaining  medical  assistance.  Finally,  it  is 
impossible  to  analyze  the  statistics  of  placenta  praevia  without  coming 
to  the  conclusion  that  the  result  depends  in  a  large  measure  upon 
the  personal  qualities  of  the  physician.  A  self-possessed  man,  cool, 
resolute,  with,  clear  ideas  of  the  anatomical  conditions  to  be  dealt 
with,  will,  if  summoned  in  season,  apparently  deprive  even  placenta 
praevia  of  a  good  share  of  its  terrors. 

Diagnosis. — There  are  no  signs  by  which  placenta  prsevia  can  be 
recognized  in  the  first  half  of  pregnancy.  It  may  occasion  abortion, 
which  is  then  characterized  by  the  absence  of  pain,  both  previous  to 
the  haemorrhage  and  during  the  period  of  expulsion.  As  a  rule,  the 
ovum  is  expelled  entire  without  rupture  of  the  membranes.  In  the 
second  half  of  pregnancy,  a  haemorrhage  occurring  suddenly,  without 
ostensible  cause  and  without  warning,  should  always  be  regarded  with 
suspicion.  Upon  digital  exploration  in  placenta  praevia  the  vaginal 
fornix  is  found  soft  and  boggy,  and  occasionally  thicker  upon  the  one 
side  than  upon  the  other,  where  the  placental  presentation  is  incom- 
plete ;  ballottement  is  obscure  ;  the  cervix  is  long,  wide,  and  soft,  and 
contains  at  times  vessels  which  pulsate  distinctly  ;  the  cervical  canal 
permits  the  passage  of  the  finger  to  the  os  internum,  which  at  first 
offers  resistance,  but  yields  to  gentle  force.  The  diagnosis  is  rendered 
positive  only  in  cases  where  the  lower  surface  of  the  placenta  is 
actually  felt  through  the  cervix,  its  rough,  spongy,  granular  texture 
suflBciently  distinguishing  it  from  clots  and  other  possible  sources  of 
deception. 

Treatment. — The  history  of  placenta  praevia  brings  into  prominence 
the  central  point  to  be  kept  steadily  in  view  in  practice,  that  there  is 
no  safety  for  the  mother  so  long  as  pregnancy  continues.  In  a  very 
large  proportion  of  cases,  accidental  haemorrhage  occurring  in  the  first 
half  of  pregnancy  leads  to  abortion,  the  management  of  which  does 
not  differ  from  that  of  abortions  which  take  place  in  normal  attach- 
ments of  the  placenta.  Of  the  one  hundred  and  twenty-eight  deaths 
from  placenta  praevia  collected  by  Miiller,  not  one  occurred  previous 
to  the  seventh  month.  In  the  latter  half  of  pregnancy,  haemorrhage 
likewise  leads  to  premature  expulsion  of  the  ovum  with  such  fre- 
quency that  it  is  reckoned  that  only  one  third  of  all  cases  reach  the 
end  of  gestation. 

Most  authorities  advise,  in  the  presence  of  the  haemorrhages  of  ad- 


558 


THE  PATHOLOGY  OF  LABOR. 


vanced  pregnancy,  that  the  physician  maintain  an  attitude  of  expect- 
ancy, postponing  active  interference,  except  in  cases  where  the  loss 
of  blood  assumes  alarming  proportions,  until  the  spontaneous  advent 
of  labor.  This  policy  is  recommended  partly  in  the  interest  of  the 
child,  and  partly  because  of  the  tendency  in  premature  labor  to  rigid- 
ity of  the  cervix,  a  complication  which  always  in  placenta  praevia  en- 
hances the  risks  of  delivery.  The  wisdom  of  delay  is,  however,  open 
to  serious  question.  The  fatality  of  placenta  praevia  is  due  not  so 
much  to  the  impotence  of  obstetrical  art  as  to  the  losses  of  blood 
which  occur  suddenly  in  the  absence  of  professional  assistance.  The 
first  hagmorrhage,  which  serves  as  a  warning  as  to  the  patient's  condi- 
tion, is  fortunately  in  most  instances  slight.  With  each  recurrence, 
however,  the  flow  becomes  more  profuse.  If  the  haemorrhages  begin 
before  the  child  is  viable,  the  chances  of  saving  its  life  are  in  any 
event  too  small  to  offset  for  a  moment  the  welfare  of  the  mother. 
Haemorrhages  occurring  as  early  as  the  seventh  month  are,  as  a  rule, 
the  result  of  complete  placental  presentation.  To  trifle  with  such 
cases  is  the  best  way  to  maintain  the  present  mournful  statistics. 
After  the  thirty-second  week  it  is  safe  to  say  that  the  child's  life  is 
less  imperiled  by  the  induction  of  premature  labor  than  by  exposing 
it  to  the  dangers  of  continued  gestation. 

On  theoretical  grounds,  therefore,  the  induction  of  premature  labor 
is  to  be  regarded  as  obligatory  so  soon  as  the  diagnosis  of  placenta 
praevia  is  established,  or  at  least  with  the  occurrence  of  the  first  haemor- 
rhage. The  practical  results  of  this  measure  in  the  hands  of  its  advo- 
cates *  plead  still  more  effectively  in  its  behalf.  Thus,  Dr.  Gaillard 
Thomas  f  reports  eleven  cases,  with  but  two  deaths,  one  resulting  from 
post-partum  haemorrhage  coming  on  several  hours  after  delivery,  and 
one  from  puerperal  fever.  HeckerJ  lost  three  cases  in  forty,  Hoff- 
mann two  cases  in  thirty,  and  Spiegelberg  four  cases  in  seventy-four 
early  deliveries.*  In  this  connection  I  can  not  help  quoting  the  fol- 
lowing impressive  remarks  of  Dr.  Barnes:  **If  the  pregnancy  have 
advanced  beyond  the  seventh  month  it  will,  as  a  general  rule,  I  think, 
be  wise  to  proceed  to  delivery,  for  the  next  haemorrhage  may  be  fatal ; 
we  can  not  tell  the  time  or  extent  of  its  occurrence,  and,  when  it  occurs, 
all,  perhaps,  that  we  shall  have  the  opportunity  of  doing  will  be  to 
regret  that  we  did  not  act  when  we  had  the  chance." 

In  the  management  of  placenta  praevia  it  is  very  desirable  that  the 
practitioner  should  have  a  perfectly  clear  idea  of  the  nature  of  the  task 

*  Premature  labor  in  profuse  or  continuous  hnemorrhage  has  received  the  indorse- 
ment in  this  country  of  Thomas,  Taylor,  Parvin,  Pallen,  and  Taber  Johnson. 

f  "  Trans,  of  the  N.  Y.  Obstet.  Soc,"  vol.  i.,  p.  262. 
X  Statistics  taken  from  L.  Muller's  monograph. 

*  These  statistics  do  not,  however,  like  those  quoted  from  Thomas,  include  deaths  in 
childbed.    Thus,  Spicgelbcrg's  complete  death-i'ate  reached  sixteen  {ler  cent. 


PLACENTA  PREVIA. 


559 


he  "has  to  perform.  The  birth  of  the  child  can  not  take  place  without 
preliminary  expansion  of  the  cervix.  The  cervix  can  not  expand  with- 
out detachment  of  the  placenta.  The  principal  objective  point  of 
treatment,  therefore,  is  the  haemorrhage  which  occurs  during  the  stage 
of  dilatation.  Plans  for  restricting  the  flow  within  narrow  limits  have 
been  proposed  without  number  by  masters  of  the  obstetric  art.  The 
best  plans  are  those  which  at  the  same  time  contribute  to  shorten 
labor.  The  choice  must  be  determined  by  conditions  which  neces- 
sarily vary  in  different  cases.  The  physician  has  at  the  outset  to  par- 
ticularly inform  himself  as  to  whether  labor  has  begun  or  remains  to 
be  inaugurated,  as  to  whether  the  placenta  prsevia  is  complete  or  in- 
complete, as  to  whether  the  presentation  is  normal  and  the  pains  are 
good,  as  to  whether  the  membranes  have  ruptured  or  are  intact,  and 
as  to  the  length  and  dilatability  of  the  cervix. 

If  the  cervix  is  long,  narrow,  and  rigid,  and  the  membranes  are 
entire,  the  vaginal  tampon  should  be  resorted  to  as  a  temporary  expe- 
dient. The  tampon  strengthens  the  pains,  and,  by  the  compression 
it  exerts,  causes  coagulation  of  the  blood  which  escapes  from  the  uter- 
ine vessels.  Professor  I.  E.  Taylor  advises  packing  the  vagina  with  a 
surgical  bandage,  leaving  one  end  outside  the  vulva,  by  means  of  which 
it  can  be  withdrawn  without  difficulty.  Braun,  after  many  years'  ex- 
perience at  Vienna  with  the  colpeurynter,  maintains  the  superiority  of 
hydrostatic  dilatation.  I  use  dampened  cotton,  crowding  it  into  the 
upper  portion  of  the  vagina  with  the  aid  of  a  Sims  speculum.  The 
"choice  does  not  appear  to  be  material.  Having  once  introduced  the 
tampon,  the  physician  should  not  leave  his  patient  until  the  labor  is 
ended.  After  at  most  four  hours  the  tampon  should  be  removed,  and 
the  cervix  should  be  examined. 

So  soon  as  the  os  will  permit  its  introduction,  either  the  dilator  of 
Barnes  or  of  Tarnier  should  be  employed  in  place  of  the  vaginal  plug. 
A  Barnes  rubber  bag,  expanded  sufficiently  to  render  the  border  of 
the  OS  externum  tense,  fulfills  admirably  the  principal  indications.  It 
acts  as  an  efficient  tampon,  it  strengthens  the  pains,  and  it  dilates  the 
cervical  canal.  As  the  latter  expands,  a  larger-sized  dilator  should  be 
introduced.  It  is  important,  in  order  to  prevent  haemorrhage,  to 
maintain  the  tension  of  the  external  orifice.  On  account  of  the  soft- 
ening which  exists  in  the  lower  uterine  segment  as  a  result  of  placenta 
prsevia,  in  a  large  proportion  of  cases  the  cervix  can  be  stretched  with 
the  utmost  facility.  If  no  urgent  symptoms  call  for  immediate  inter- 
ference, it  is  desirable  to  render  the  dilatation  complete.  It  is  not, 
however,  always  necessary.  Indeed,  Barnes,  Taylor,  Spiegelberg,  and 
Braun  advise  to  proceed  boldly  with  the  delivery  so  soon  as  the  os 
externum  has  expanded  to  the  size  of  a  half-dollar,  as  by  that  time  the 
expansion  of  the  os  internum  is  very  nearly  completed,  and  as  the  soft 
cervical  canal  does  not  offer  sufficient  resistance  to  materially  inter- 


560 


THE  PATHOLOGY  OF  LABOR. 


fere  with  the  extraction  of  the  child.  The  distinguished  success  of 
the  authorities  mentioned  in  the  field  of  practice  under  consideration 
lends  great  weight  to  their  recommendations.  It  is,  however,  more 
than  probable  that  exceptional  training  and  experience  count  in  their 
case  for  quite  as  much  as  the  plans  of  procedure  they  individually 
favor.  At  any  rate,  in  reviewing  the  statistics  of  Trask  and  Miiller  it 
becomes  evident  that  rigidity  of  the  cervix  is  not  a  rare  event  in  pla- 
centa praevia,  and  that  the  accouchement  force,  performed  with  a  rigid 
cervical  canal,  is  perhaps,  next  to  doing  nothing,  the  most  responsible 
cause  of  the  mournful  results  they  have  placed  on  record. 

After  the  cervix  has  been  duly  prepared,  the  membranes  should  be 
ruptured,  and  a  part  of  the  amniotic  fluid  should  be  permitted  to 
escape.  Then,  if  the  placenta  possesses  a  lateral  or  a  marginal  attach- 
ment, if  the  pelvis  is  of  normal  size  and  the  pains  strong  and  regu- 
lar, and  if  the  head  present,  or  at  least  can  be  brought  down  and 
fixed  at  the  pelvic  brim  by  external  manipulations,  the  further  prog- 
ress of  the  case  may  be  left  to  Nature.  Haemorrhage  will  then  be  jDre- 
vented  by  the  pressure  of  the  foetus  in  its  descent  through  the  utero- 
vaginal canal.  At  first  the  method  of  expression  advocated  by  Kris- 
teller  is  capable  of  rendering  important  service  by  promoting  the 
sjDeedy  engagement  of  the  child's  head.  Ergot,  too,  cautiously  admin-  \ 
istered,  is  useful  in  strengthening  the  uterine  contractions.  Even  if  ; 
tonic  contraction  follow  from  its  employment — an  unlikely  event  in 
placenta  praevia — the  effect  would  be  to  close  the  sinuses  and  to  fur-  < 
nish  afresh  barrier  against  haemorrhage.  The  forceps  may  be  a^^plied  j 
under  the  same  circumstances,  and  with  the  same  restrictions,  as  in  | 
other  conditions.  Where,  however,  the  head  is  movable,  the  patient 
anaemic,  and  haemorrhage  persistent,  version,  as  furnishing  the  more 
rapid  mode  of  delivery,  would  receive  the  preference. 

In  cases  of  complete  attachment  of  the  placenta  there  should  be 
no  trifling  with  half-way  measures.  If  the  cervix  is  long  and  rigid, 
the  vaginal  tampon  should  be  employed  as  a  preliminary  measure. 
When  the  cervical  tissues  have  become  softened,  and  dilatation  has 
begun,  the  tampon  should  be  removed.  At  this  stage  Barnes  recom- 
mends sej^arating  at  once  that  portion  of  the  placenta  which  is  attached 
above  the  inner  orifice  of  the  cervix.  ^  By  so  doing,  ^^we  remove  an 
obstacle  to  the  dilatation  of  the  cervix,  for  the  adherent  placenta  acts 
as  an  impediment."  The  operation  is  performed  as  follows:  "Pass 
one  or  two  fingers,  as  far  as  they  will  go,  through  the  os  uteri,  the  hand 
being  passed  into  the  vagina  if  necessary ;  feeling  the  placenta,  insinu- 
ate the  finger  between  it  and  the  uterine  wall ;  sweep  the  finger  around 
in  a  circle,  so  as  to  separate  the  placenta  as  far  as  the  finger  can 
reach.  .  .  .  Commonly  some  amount  of  retraction  of  the  cervix  takes 
place  after  this  operation,  and  often  the  haemorrhage  ceases."*  Next 

*  Barnes,  "  Obstetrical  Operations,"  p.  503.   The  artificial  separation  of  the  placenta 


PLACENTA  PR.^:VIA. 


561 


put  in  a  Barnes  dilator  and  rapidly  expand  the  cervix.  Meantime 
try  and  bring  the  breech  down  into  the  lower  uterine  segment  by 
external  palpation.  Both  Taylor  and  Braun  have  found  external  ver- 
sion easy,  on  account  of  the  inert  conditions  of  the  uterine  walls. 
When  the  cervix  has  been  sufificiently  stretched  to  admit  of  delivery, 
two  fingers  should  be  introduced,  the  placenta  should  be  separated, 
the  membranes  ruptured,  and  an  extremity  should  be  seized  without 
passing  the  entire  hand  into  the  uterus.  Extraction  should  then  fol- 
low, the  pressure  of  the  foetus  preventing  any  considerable  amount  of 
haemorrhage. 

Usually  the  right  hand  is  chosen  to  seek  the  feet,  as  the  placenta 
more  frequently  overlaps  the  left  side.  Many  times,  however,  it  will 
be  necessary  to  change  the  direction  of  the  fingers  before  the  edge  of 
the  placenta  is  reached.  If  external  version  can  not  be  effected,  the 
operator  should  push  the  hand  forward  into  the  uterus  to  find  an  ex- 
tremity. The  arm  acts  during  the  search  as  a  temporary  tampon. 
Haemorrhage,  which  follows  the  withdrawal  of  the  arm,  will  be  arrest- 
ed by  the  descent  of  the  breech . 

The  accidental  rupture  of  the  membranes  before  the  cervix  is  pre- 
pared for  artificial  delivery  is  hardly  likely  to  occur  in  cases  of  pla- 
centa praevia  completa.  In  cases  of  marginal  implantation,  dilatation 
with  water-bags  should  be  employed  in  such  a  way  as  to  compress  the 
open  sinuses  from  which  bleeding  takes  place. 

After  the  birth  of  the  child,  the  danger  of  post-partum  haemor- 
rhage must  be  kept  in  mind.  Every  preparation  should  be  made  in 
anticipation  of  its  occurrence.  If  bleeding  persists  after  the  fundus  is 
felt  to  be  firmly  contracted,  a  speculum  should  be  introduced,  and  the 
open  sinuses  of  the  lower  segment  should  be  swabbed  with  cotton 
soaked  in  some  styptic  form  of  iron,  as  recommended  by  Engelmann 
{vide  "Post-partum  Haemorrhage").  Ergot  should  be  given  for  sev- 
eral days,  as  the  danger  of  late  haemorrhages  is  specially  great  follow- 
ing placenta  praevia. 

The  utmost  cleanliness  and  the  use  of  disinfectant  vaginal  douches 
must  be  insisted  on  during  the  childbed  period,  as  the  exposure  of  the 
placental  wound  to  the  lochia,  which  constantly  flow  over  it,  renders 
the  patient  especially  liable  to  septic  infection. 

Haemorrhage  from  Normally  Implanted  Placenta.— The  placenta, 
even  when  implanted  over  the  upper  polar  circle,  the  safe  placental 
seat  of  Dr.  Barnes,  may  become  detached  to  a  greater  or  less  extent, 
during  pregnancy  or  labor,  and  may  then  furnish  a  flow  of  blood  that 
either  remains  internal  and  concealed  or  may  find  its  way  between 
the  decidua  vera  and  reflexa  and  thus  escape  into  the  vagina. 

is  unquestionably  of  service  where  it  can  be  accomplished  without  difficulty.    Much  time 
should  not,  however,  be  lost  in  fruitless  efforts,  nor  is  it  desirable  to  persist  if  the  sepa- 
ration can  not  be  accomplished  smoothly. 
36 


562 


THE  PATHOLOGY  OF  LABOR. 


The  haemorrhages  from  this  variety  of  placental  separation  are 
termed  ^'accidental,"  in  contradistinction  to  the  "unavoidable" 
form,  which  is  the  accompaniment  of  placenta  prsevia. 

The  circumstances  under  which  concealed  haemorrhage  takes  place 
are  given  by  Goodell*  as  follows  :  (a)  When  the  placenta  is  centrally 
detached,  and  the  blood  accumulates  in  the  cul-de-sac  formed  by  the 
firm  adhesion  of  its  margins  to  the  uterine  wall,  (b)  When  the  pla- 
centa is  so  detached  that  the  blood  escapes  into  the  uterine  cavity 
behind  the  membranes  near  the  fundus,  (c)  When  membranes  are 
ruptured  near  the  detached  placenta  and  the  effused  blood  mingles 
with  the  liquor  amnii.  (d)  When  the  presenting  part  of  the  foetus 
so  accurately  plugs  up  the  maternal  outlet  that  no  existing  haemor- 
rhage can  escape  externally. 

The  causes  of  internal  haemorrhage,  when  such  can  be  determined, 
are  for  the  most  part  similar  to  those  considered  in  connection  with 
abortion.  Thus,  the  circumstances  leading  to  placental  detachment 
Goodell  found  to  be  irregular  uterine  contractions,  external  violence, 
and  undue  exertion. ;  in  seven  the  causes  were  purely  emotional,  and 
ten  took  place  during  sleep.  It  occurs  more  frequently  in  multiparas 
and  in  the  latter  months  of  pregnancy. 

The  symptoms  are  an  alarming  state  of  collapse,  pain  often  exces- 
sive, absence  or  extreme  feebleness  of  the  pains  of  labor,  marked  dis- 
tention of  the  uterus,  sometimes  a  lateral  bulging  of  the  uterine  walls, 
a  show  of  blood,  a  serous  discharge,  and  blood  in  the  liquor  amnii. 

The  diagnosis  in  the  concealed  form  may  be  extremely  embarrass- 
ing. The  pain  is  often  that  of  flatulent  colic.  The  accident  likewise 
presents  many  features  which  resemble  those  of  ruptured  uterus,  but 
rupture,  by  contrast,  rarely  occurs  until  after  the  escape  of  the  waters, 
the  presenting  part  then  receding  from  the  os,  and  the  uterus  dimin- 
ishing in  size. 

The  prognosis  is  very  unfavorable.  Goodell  reports  :  "  Out  of  one 
hundred  and  six  tabulated  cases,  fifty-four  mothers  perished  ;  and  out 
of  one  hundred  and  seven  children  six  alone  are  known  to  have  been 
saved."  I  have  had  a  case  since  his  paper,  where,  after  labor,  I  re- 
moved at  least  a  basinful  of  firm  clots  from  the  uterine  cavity,  and  yet 
both  mother  and  child  survived. 

In  cases  of  external  haemorrhage  the  diagnosis  is  easy  and  the 
prognosis  more  favorable,  the  latter  probably  because  the  walls  are  less 
flaccid  than  in  the  concealed  form. 

The  treatment  consists  in  the  subcutaneous  injections  of  ergot,  in 
dilatation  of  the  os  with  Barnes  dilators,  in  rupture  of  the  membranes, 
and  in  version. 

*  Goodell,  "On  Concealed  Accidental  Hfemorrhage  of  the  Gravid  Uterus"  ("Am. 
Jour,  of  Obstet.,"  August,  1869,  p.  281).  This  paper  serves  as  a  mine  from  which  most 
subsequent  writers  have  drawn  their  data. 


PLACENTA  PRiEVIA. 


563 


In  my  own  case,  to  which  I  have  referred,  the  Barnes  dilator  acted 
capitally,  not  only  enabling  me  to  expand  the  cervix,  but  exciting  the 
uterus  to  contract  vigorously.  The  serious  symptoms  set  in  after  the 
membranes  were  ruptured,  and  compelled  me  to  deliver  with  forceps. 
In  another  case  I  should  certainly  first  dilate,  and,  after  rupture  of  the 
membranes,  should  choose  version  and  speedy  extraction,  and  should 
avail  myself  of  a  skilled  assistant,  whose  duty  it  should  be  to  compress 
the  uterine  walls  externally  during  the  act  of  delivery. 

Inversio  Uteri. — Inversion  of  the  uterus  is  a  rare  occurrence. 
Braun  states  that,  of  one  hundred  and  fifty  thousand  births  in  the 
clinics  respectively  under  the  charge  of  Spaeth  and  himself,  not  a  sin- 
gle complete  inversion  has  come  to  their  notice.  There  was  one  case 
in  one  hundred  and  ninety  thousand  confinements  at  the  Rotunda 
Hospital  in  Dublin. 

The  production  of  inversion  is  favored  by  a  large,  relaxed  uterus, 
the  result  of  over-distention,  of  rapid  delivery,  or  of  haemorrhage. 
The  immediate  cause  may  be  either  pressure  exerted  from  above  or 
traction  from  below.  The  first  may  proceed  from  straining  efforts, 
especially  in  a  sitting  or  kneeling  position,  or  from  attempts  at  pla- 
cental expulsion  before  uterine  contractions  have  been  secured  ;  the 
second  may  proceed  from  a  short  or  coiled  cord  during  expulsion, 
from  tractions  upon  the  cord  after  the  child  is  born,  or  simply  from 
the  weight  of  the  placent-a.  Hennig*  concludes  that  the  attachment 
of  the  placenta  to  the  fundus,  instead  of  a  more  lateral  implantation, 
is  an  active  cause  of  the  accident. 

Inversion  may  be  partial  or  complete.  In  the  former  the  fundus 
presents  a  saucer-  or  cup-like  depression  ;  in  the  latter  the  entire 
fundus  descends  into  the  vagina  ;  in  extreme  instances  the  cervix  may 
be  inverted  to  the  vaginal  attachment.  Dr.  I.  E.  Taylor  maintains  a 
mechanism  for  a  certain  number  of  cases,  which  consists  in  a  rolling- 
out  of  the  cervix,  with  gradual  implication  of  the  body  and  fundus. 

The  symptoms  of  inversion  are  shock  and  haemorrhage.  The  shock 
is  evidenced  by  the  small  pulse,  cold  extremities,  vomiting,  and  sunken 
features,  and  is  due,  in  part  at  least,  to  the  sudden  diminution  of  the 
intra-abdominal  pressure  and  consequent  plethora  of  the  abdominal 
veins  ;  the  haemorrhage  results  from  imperfect  contraction,  and  is 
therefore  proportioned  to  the  extent  of  the  uterine  paresis. 

Spontaneous  reduction  of  incomplete  inversion  is  not  uncommon. 
Cases  of  spontaneous  reduction  of  the  complete  form  have  likewise 
been  observed,  referable,  according  to  Spiegelberg,f  to  retraction  of 
the  ligaments  acting  upon  the  uterus  while  in  a  relaxed  condition. 

The  diagnosis  is  not  difficult.     The  inverted  uterus  can  only  be 

*  Hennig,  "  Ueber  die  Ursachcn  der  spontancn  Inversio  Uteri,"  "  Arcb.  f .  Gynaek.," 
Bd.  vii,  p.  491. 

f  Spiegelberg,  *'  Lehrbuch,"  etc.,  p.  597.. 


564 


THE  PATHOLOGY  OF  LABOR, 


mistaken  for  a  fibrous  polypus,  but  by  careful  external  and  bimanual 
palpation  the  demonstration  of  the  absence  of  the  uterine  tumor  above 
the  symphysis  would  guard  against  this  error. 

The  prognosis  depends  upon  the  promptitude  of  the  operator  in 
restoring  the  fundus  to  its  normal  position.  Still,  according  to 
Crosse's*  statistics,  one  third  of  the  patients  died  either  at  once  or 
within  a  month  of  the  occurrence  of  the  accident. 

Treatment  consists  in  pressing  the  fundus  upward  with  the  fingers 
or  with  the  closed  fist.  To  avoid  tearing  the  uterus  from  its  vaginal 
attachments,  care  should  be  taken  to  employ  counter-pressure  with 
the  disengaged  hand  upon  the  upper  border  of  the  funnel-shaped  de- 
pression. If  the  placenta  is  detached  to  any  great  extent,  its  separa- 
tion should  be  completed  before  replacement ;  if  adherent,  no  time 
should  be  lost,  but  placenta  and  fundus  should  be  pushed  back  together. 
If  the  cervix  is  contracted  about  the  inverted  portion,  an  anaesthetic 
should  be  given,  and  taxis  should  be  employed.  I  can  speak  from  ex- 
perience in  favor  of  Noeggerath's  method,  which  consists  in  indenting 
the  uterus  in  the  neighborhood  of  a  Fallopian  tube,  in  place  of  acting 
directly  upon  the  fundus.  If  the  reinversion  proves  successful,  the 
hand  should  be  allowed  to  remain  within  the  uterus,  and  external 
pressure  should  be  employed  until  contraction  is  secured.  The  re- 
maining treatment  does  not  differ  from  that  for  uterine  atony,  already 
considered  in  connection  with,  post-partum  haemorrhage. 


CHAPTER  XXXIII. 

EUPTUBE8  OF  THE  GENITAL  CANAL, 

Rupture  of  the  uterus. — Etiology. — Pathological  anatomy. — Symptoms  and  diagnosis. — 
Treatment. — Prophylaxis. — Treatment  after  rupture. — Rupture  limited  to  the  peri- 
toneal covering  of  the  uterus. — Perforation  from  pressure. — Lacerations  of  the  vaginal 
portion. — Laceration  of  the  vagina. — Laceration  of  the  vulva. — Thrombus  of  the 
vulva  and  vagina. — Rupture  of  the  pelvic  articulations. 

The  genital  canal  may  be  ruptured  in  any  portion  of  its  course. 
Thus,  lacerations  may  take  place  through  the  perinaeum  and  posterior 
vaginal  wall,  in  the  vestibulum,  in  the  fornix  of  the  vagina,  in  the 
cervix,  in  the  uterus,  and  in  the  pelvic  articulations. 

Rupture  of  the  Uterus. — Ruptures  of  the  uterus,  for  the  most  part 
at  least,  start  from  the  lower  segment  and  thence  extend  upward 
toward  the  body  and  fundus,  or  downward  toward  the  vagina.  They 
are  termed  complete  when  the  rent  extends  through  to  the  abdominal 

*  Crosse,  "  An  Essay,  Literary  and  Practical,  on  Invcrsio  Uteri,"  "  Trans,  of  the 
Provincial  Med.  and  Surg.  Assoc.,  1847,"  p.  344.  (Spicgelbcrg.) 


RUPTURES  OF  THE  GENITAL  CANAL. 


565 


cavity,  and  incomplete  when  confined  to  either  the  muscular  layers  or 
to  the  peritonaeum. 

Bandl  reported  19  cases  in  40,614  labors  (1  :  2,137),  occurring  in 
nine  years  in  the  Lying-in  Hospital  at  Vienna.  Jolly,  in  Paris,  found 
230  cases  in  782,741  labors  (1  : 3,403),  but  he  excluded  from  his  list 
lacerations  of  the  cerA'ix.  Harris,  whose  authority  as  a  statistician  is 
of  the  highest,  estimates  in  the  United  States  one  case  of  ruptured 
uterus  to  four  thousand  births.  I  found  47  deaths  from  this  cause 
recorded  in  Xew  York  between  1867  and  1875  inclusive,  or  about  one 
death  in  six  thousand  labors.  But  it  is  hardly  probable  that  these 
figures  represent  anything  like  the  actual  mortality ;  for,  whereas  in 
1875  eleven  deaths  were  returned,  there  were  but  four  recorded  in  1867, 
and  none  in  the  years  1871  and  1872.  It  is  not  likely,  moreover,  that 
the  47  cases  include  any  other  than  spontaneous  ruptures,  as  naturally 
very  few  physicians  are  honest  enough  to  record,  as  such,  ruptures  due 
to  violent  obstetric  manoeuvres. 

Hugenberger  estimated  the  mortality  from  ruptured  uterus  at  95 
per  cent.,  C.  Braun*  at  89  per  cent.  Their  statistics  were  made  up 
from  hospital  records.  Jolly  reported  in  civil  practice  100  saved  in 
580  cases,  but  this  Harris  f  believes  to  be  too  favorable  a  showing, 
as  the  proportionate  loss  is  much  less  in  published  than  in  unpub- 
lished cases.  The  treatment  of  this  condition  is,  therefore,  compara- 
tively ineffective  ;  a  careful  study  of  the  circumstances  which  favor  its 
production  is,  however,  capable  of  at  least  furnishing  the  ground- 
work of  a  rational  prophylaxis. 

Etiology. — Rupture  of  the  uterus  may  take  place  spontaneously  as 
the  result  of  defective  resistance  off'ered  by  the  uterine  walls  to  the 
pressure  of  the  ovum,  or  it  may  owe  its  origin  to  some  external  me- 
chanical force. 

Rupture  of  the  fundus  is  a  very  rare  exception.  It  is  said  to  take 
place  under  special  abnormal  conditions,  as  in  the  one-horned  uterus, 
in  imbedded  myomata,  when  cicatrices  exist  as  the  result  of  previous 
Caesarean  section,  and  in  retrograde  changes  of  the  uterine  walls. 

It  is  the  great  merit  of  Bandl  I  to  have  shown  that  nearly  all  rupt- 
ures begin  in  the  lower  segment,  and  are  preceded  by  an  abnormal 
thinning  and  distention  of  that  portion  of  the  uterus  situated  between 
the  ring  which  bears  his  name  and  the  os  externum.  In  normal  labor 
it  will  be  remembered  that  during  a  pain  the  fundus  and  body  thicken, 
while  the  lower  segment  is  stretched  by  the  ovum.  So  long  as  no  ob- 
stacle exists  which  hinders  the  progression  of  the  ovum  or  the  foetus, 
this  process  ends  in  the  conversion  of  the  uterus  and  vagina  into  one 

*  Braun,  "  Lchibuch  der  gcsammt.  Gynaek,,"  p.  699. 

•f  Harris,  "  If  a  Woman  has  ruptured  her  Uterus,  what  shall  bo  done  in  order  to 
save  her  Life  V  "  "Am.  Jour,  of  Obstet,"  October,  1880. 
X  Bandl,  "  Ueber  Ruptur  der  Gebarmutter,"  Wien,  1875. 


566 


THE  PATHOLOGY  OF  LABOR. 


continuous  canal.  In  such  cases  the  ring  of  Bandl  is  found  in  the 
neighborhood  of  the  pelvic  brim. 

If,  however,  the  descent  of  the  foetus  is  prevented  hy  any  cause, 
the  resistance  of  the  ligaments  which  hold  the  uterus  in  position  is 
overcome  by  the  retraction  of  the  fundus  and  body,  and  as  a  conse- 
quence the  ring  of  Bandl  is  withdrawn  upward,  the  lower  segment  is 
thinned,  while  in  extreme  cases  the  thickened  fundus  simply  covers 

the  pelvic  extremity  of  the 
child  like  an  inverted  bowl. 
Under  these  circumstances 
it  is  possible  at  times  to  de- 
tect by  palpation  the  ring  of 
Bandl  a  hand's-breadth  above 
the  pubes,  or  even  in  the 
neighborhood  of  the  umbili- 
cus. The  stretching  of  the 
tissues  is  most  pronounced  in 
the  upper  portion  of  the 
lower  segment,  diminishing 
below  until  the  vaginal  por- 
tion is  reached,  which,  of 
course,  is  not  subjected  to 
tension. 

In  another  place  we  have 
noticed  that  it  is  an  unde- 
cided question  whether  the 
tensile  structures  beneath  the 

Fig.  222.— "Diagram  showing  dangerous  thinning  ot  ring  of  Bandl  belong  prop- 
the  lower  segment,  owing  to  the  non-descent  p^l  vl-n nfpvn a  nrwlioflior 
of  the  head  in  contracted  pelvis.    (Bandl. )  ^^^J      ^^^^  ^^^'^^  Whether 

they  are  derived  from  the 

cervix,  which  has  been  partially  opened  by  the  growth  of  the  ovum. 

Spiegelberg  terms  this  portion  the     obstetrical  cervix,"  an  expression 

which  happily  defines  its  function  without  attempting  to  account  for 

its  origin. 

Now,  when,  as  the  result  of  the  birth  of  any  considerable  portion 
of  the  child  into  the  obstetrical  cervix,  the  tissues  of  the  latter  are 
stretched  so  as  to  form  little  more  than  a  membranous  covering,  the 
conditions  which  threaten  rupture  are  established.  Thus,  contractility 
is  lost  with  each  recurring  pain,  the  child,  driven  still  farther  from 
the  uterine  cavity,  increases  the  pressure  upon  tlie  already  enormously 
distended  cervix  ;  gradually  the  thinned  tissues  separate  ;  the  present- 
ing part  of  the  child  is  forced  into  the  opening  ;  at  tlie  height  of  a 
pain  complete  perforation  of  the  cervical  substance  takes  place ;  tlie 
peritona3um  is  lifted  up  from  the  underlying  tissue,  and  finally,  in  the 
majority  of  cases,  is  torn  through,  permitting  the  partial  or  complete 


RUPTURES  OF  THE  GEXITAL  CANAL. 


567 


passage  of  the  child  into  the  peritoneal  cavity.  The  emptied  uterus 
then  contracts,  and  the  expulsive  pains  cease.  The  conditions  which, 
according  to  Bandl,  especially  predispose  to  dangerous  cervical  tension 
are  pelvic  contraction,  shoulder  presentations,  and  hydrocephalus. 
Eupture  is  favored  whenever  the  tension,  as  in  lateral  obliquity  and 
anteflexion  of  the  uterus,  and  in  transverse  presentations,  falls  more 
upon  one  side  of  the  lower  segment  than  upon  the  other. 

There  are  very  great  individual  differences  in  the  distensibility  of 
the  cervical  tissues.    In  women  who  have  borne  many  children,  rupt- 


Fia.  223.— Case  of  ruptured  uterus  (anterior  Burface).    a,  body  of  uterus  ;  5,  ring  of  Bandl ; 
c,  thrombus,  shining  through  the  peritonaeum. 

ure  may  occur  before  any  great  degree  of  stretching  has  been  reached. 
In  the  case  of  which  the  post-mortem  appearances  are  given  in  Fig. 
223,  spontaneous  rupture  occurred  in  the  tenth  pregnancy.  Labor 


568 


THE  PATHOLOGY  OF  LABOR. 


commenced  at  noon,  and  the  membranes,  which  had  begun  to  protrude 
through  the  vulva,  broke  near  midnight.  The  pains  then  became  slow 
and  feeble.  At  about  three  o'clock  in  the  morning  sudden  collapse 
occurred.  On  my  arrival,  thirty  minutes  later,  I  found  the  pulse 
scarcely  perceptible,  the  breathing  hurried,  and  the  extremities  cold. 
As  the  head  was  well  down  in  the  pelvis  I  applied  forceps,  and  ex- 
tracted without  effort  a  dead  child  weighing  ten  and  a  half  pounds. 
Previous  to  the  collapse  the  patient  had  felt  comfortable.  At  the 
moment  of  its  occurrence  a  distinct  snapping  sound  was  heard  by  the 
hospital  physician,  Dr.  J.  D.  Griffith,  who  sat  several  yards  distant 
from  the  bedside.  The  patient  stated  that  she  felt  a  sensation  as 
though  a  warm  fluid  was  pouring  into  the  abdominal  cavity.  As  the 
pelvis  was  ample  and  the  presentation  normal,  and  as  there  was  no 
irregularity  of  the  labor-pains,  the  rupture  could  only  be  accounted 
for  by  assuming  a  vulnerability  of  the  uterine  tissues,  and  probably  a 
clamping  of  the  anterior  lip  between  the  head  and  the  pelvic  wall. 

On  the  other  hand,  so  great  is  the  distensibility  of  the  tissues  in 
certain  cases  that  the  foetus  may  pass  entire  from  the  uterus  into  the 
cavity  of  the  obstetrical  cervix  without  laceration  ensuing.  • 

Bandl  found  that  of  546  cases  of  rupture  but  sixty-four  were  in  pri- 
miparse.  Their  preponderance  in  multiparse  is  for  the  most  part  the 
result  of  the  laxity  of  the  round  and  lateral  ligaments  of  the  uterus, 
which  offer  accordingly  but  slight  resistance  to  the  recession  of  the 
ring  of  Bandl ;  of  the  stretched  condition  of  the  abdominal  parietes, 
which  permits  obliquities  and  anteflexion  to  take  place  ;  and  of  the 
separation  of  the  recti  muscles,  which  interferes  with  the  use  of  the 
abdominal  compress. 

Of  course,  the  loss  of  vitality  over  limited  areas,  resulting  from  the 
compression  to  which  the  uterine  walls  are  frequently  subjected  in 
deformed  pelves,  enhances  the  disposition  to  rupture.  It  is  likewise 
obvious  that  the  existence  of  extreme  cervical  distention  should  not 
be  overlooked  in  cases  where  operations  are  rendered  necessary.  The 
old  prejudice  against  all  operations  within  the  uterine  cavity  while 
the  cervix  is  undilated  is  based  in  great  measure  upon  the  real  danger 
of  laceration  which  proceeds  from  the  association  in  many  cases  of  the 
foregoing  condition  with  difficult  labor. 

Pathological  Anatomy. — Eupture  may  occur  in  any  point  of  the 
obstetrical  cervix.  More  commonly  it  takes  place  upon  the  side. 
Owing  to  the  right  lateral  obliquity  of  the  uterus,  and  the  greater 
frequency  in  shoulder  presentations  of  head-left  positions,  the  left  side 
is  oftener  affected  than  the  right.  The  laceration  may  follow  any 
direction.  Longitudinal  tears  occur  usually  in  shoulder  presenta- 
tions, or  where  the  head  is  of  disproportionate  size  ;  the  circular  rents 
are  for  the  most  part  limited  to  generally  contracted  pelves.  The 
combination  of  a  transverse  with  a  longitudinal  tear,  the  two  meeting 


RUPTURES  OF  THE  GENITAL  CANAL. 


569 


at  a  right  angle,  is  not  uncommon.  When  the  uterine  walls  possess 
unusual  distensibility,  a  laceration  may  take  place  in  the  peritonaeum 
while  the  muscular  structures  remain  intact.  Again,  in  some  cases, 
owing  to  an  excessive  elasticity  of  the  peritonaeum,  the  latter  may  not 
give  way  even  when  the  child  has  partially  escaped  from  the  uterine 
cavity.  These  incomplete  ruptures  are  only  possible  upon  the  sides  of 
the  uterus,  at  the  site  of  the  folds  of  the  broad  ligament.  The  peri- 
toneal wound  is  usually  more  extensive  than  the  uterine. 

Some  separation  of  the  peritonaeum  from  the  underlying  structures 
is  usually  found  in  the  neighborhood  of  the  rupture.  Its  extent  is 
dependent  upon  the  degree  of  tension  to  which  the  membrane  was 
subjected  before  laceration  took  place.  At  the  body  of  the  uterus  the 
close  connection  between  the  peritonaeum  and  the  external  muscular 
layer  renders  a  separation  at  that  point  an  impossibility. 

In  the  case  represented  by  Fig.  223  the  peritonaeum  was,  on  the 
other  hand,  dissected  away  anteriorly  by  effused  blood  as  far  as  the 
umbilicus.  Haematomata  are  the  rule  in  incomplete  ruptures ;  in 
complete  ones  they  are  also  found  in  cases  where  the  peritonaeum 
has  been  late  in  giving  way — i.  e.,  after  a  cavity  of  considerable  size 
has  been  formed  by  its  detachment.  The  borders  of  the  laceration 
are  ragged.  The  body  of  the  uterus  rises  high  up  in  the  abdominal 
cavity,  and  is  inclined  to  the  side  opposite  to  that  at  which  the  rupture 
has  taken  place. 

Symptoms  and  Diagnosis. — The  occurrence  of  rupture  may  some- 
times be  foreseen  and  guarded  against  by  the  early  recognition  of  exces- 
sive cervical  distention.  The  development  of  the  latter  is  possible  in 
any  case  of  obstructed  labor.  Unless  the  abdominal  walls  are  very 
thick,  the  boundary  between  the  body  of  the  uterus  and  the  thinned 
lower  segment,  in  the  form  of  a  transverse  or  an  oblique  furrow,  may 
be  made  out  by  palpation  through  the  abdominal  walls.  Upon  the 
sides  the  round  ligaments,  even  between  the  pains,  have  the  feel  of 
tense  cords.  Usually  the  stretching  of  the  cervix  is  associated  with 
violent  pain,  with  increased  rapidity  of  pulse,  and  an  anxious  expres- 
sion of  countenance. 

If  rupture  takes  place,  and  a  portion  of  the  child  is  extruded,  the 
uterus  inclines  to  the  opposite  side,  and  often  vomiting  sets  in.  When 
the  rupture  takes  place  gradually,  violent  manifestations  are  excep- 
tional. The  j)ains  then  continue,  as  a  rule,  and  force  the  foetus  into 
the  abdominal  cavity. 

In  cases  of  sudden  rupture  the  pains  cease  instantly,  and  symptoms 
of  collapse  make  their  appearance.  Vomiting,  prostration,  the  cool 
skin,  the  rapid  pulse,  the  drawn  features,  all  point  to  internal  haemor- 
rhage and  shock.  Blood  flows  from  the  vagina,  and  the  presenting 
part  recedes  from  the  pelvic  brim. 

Certainty  in  diagnosis  is  reached  when  the  uterus  upon  palpation 


570 


THE  PATHOLOGY  OF  LABOR. 


is  found  to  be  empty,  and  the  outlines  of  the  child  can  be  made  out 
through  the  abdominal  coverings.  If  rupture  takes  place  after  the 
presenting  part  has  become  fixed  in  the  pelvis,  internal  exploration 
is  often  out  of  the  question  previous  to  the  birth  of  the  child.  Usu- 
ally, however,  the  existence  of  the  rent  is  easily  made  out  by  the 
examining  hand. 

The  passage  of  the  child  through  the  opening  into  the  abdominal 
cavity  is  usual,  but  to  this  rule  there  are  exceptions.  I  have  seen  three 
cases,  two  complete  and  one  incomplete,  where  the  child  remained 
within  the  uterus  in  spite  of  the  existence  of  extensive  laceration. 

The  symptoms  of  incomplete  rupture  are,  at  the  time  of  its  occur- 
rence, of  less  severity  than  the  foregoing.  The  pain  and  collapse,  the 
cessation  of  uterine  contractions,  and  the  recession  of  the  presenting 
part  are  usually  absent.  Often  the  rupture  may  have  existed  for  some 
time  without  appreciable  phenomena  pointing  to  its  existence.  The 
frequent  pulse  is  the  most  constant  sign.  As  incomplete  ruptures . 
have  almost  always  a  lateral  situation,  large  vessels  are  apt  to  be  in- 
jured, and  the  internal  haemorrhage  to  be  profuse. 

In  very  rare  cases  sub-23eritoneal  emphysema,  due  to  the  entrance 
of  air  or  gases  arising  from  putrefaction,  may  be  recognized  by  the 
hand  or  by  the  ear  on  the  anterior  surface  or  upon  the  sides  of  the 
uterus,  and  extending  sometimes  into  the  iliac  regions. 

Treatment — Prophylaxis. — In  view  of  the  serious  prognosis  in  cases 
of  uterine  rupture,  the  question  of  prophylaxis  is  one  of  peculiar 
interest  and  importance.  The  outcome  of  Bandl's  demonstration 
regarding  the  etiology  of  the  accident  is  to  place  in  a  clear  light  the 
responsibility  of  the  physician  for  its  occurrence.  If  it  can  not  always 
be  foreseen  and  prevented,  there  is  no  excuse  for  the  accident  when 
the  development  of  the  recognizable  conditions  w^hich  lead  to  it  is 
overlooked,  or  where  palpable  warnings  are  neglected. 

In  multiparae  with  contracted  pelves,  where,  as  a  consequence  of 
previous  pregnancies,  the  ligaments  are  lax  and  the  lower  segment  is 
soft  and  distensible,  it  is  desirable,  so  soon  as  the  child  is  viable,  to 
induce  premature  labor,  and  thus  to  diminish  the  disproportion  be- 
tween the  head  and  the  pelvis. 

If  the  conditions  described  by  Bandl  begin  to  develop  during  labor, 
lateral  obliquities  should  be  corrected,  either  by  placing  the  patient 
upon  the  side  to  which  the  presenting  part  is  turned,  or  by  fixing  the 
uterus  with  compresses  and  a  bandage  in  the  median  line. 

If  the  recession  of  the  body  of  the  uterus  continues,  and  the  head 
is  movable,  version  should  be  performed,  provided  always  that  it  can 
be  accomplished  without  violence.  In  the  introduction  of  the  hand 
every  pains  should  be  taken  to  correctly  appreciate  the  additional 
strain  to  which  the  cervical  tissues  are  subjected.  When  an  extremity 
has  been  seized,  and  tractions  are  made,  tlic  contraction  ring  which 


RUPTURES  OF  THE  GENITAL  CANAL. 


571 


separates  the  body  from  the  lower  segment  interferes  alike  with  the 
descent  of  the  breech  and  the  ascent  of  the  head  into  the  fundus.  If 
rude  force  is  employed,  the  increased  pressure  that  temporarily  is  ex- 
erted upon  the  side  of  the  cervix  which  is  bulged  by  the  presenting 
part  can  easily  give  rise  to  rupture.  To  avoid  any  unnecessary  strain 
during  version,  counter-pressure  should  be  made  over  the  fundus  of 
the  uterus  by  a  trained  assistant,  while  the  operator  controls  the  di- 
rection of  the  head  by  means  of  his  free  hand  laid  upon  the  abdominal 
wall. 

If  the  head  is  fixed  in  the  pelvis,  the  forceps  is  usually  available. 
If,  however,  the  head  is  movable  and  version  contraindicated,  the  for- 
ceps is  not  likely  to  help  the  child, 
and  is  nearly  certain  to  injure  the 
mother.  In  a  few  cases  it  is  pos- 
sible to  press  the  head  into  the 
pelvis  by  force  exerted  with  the 
two  hands  from  above  the  pubes. 

If  craniotomy  becomes  neces- 
sary, Bandl  advises  seizing  the 
head  in  the  forceps  before  using 
the  perforator,  as  even  moderate 
pressure  upward  in  the  tense  state 
of  the  cervix  may  lead  to  lacera- 
tion. 

In  neglected  shoulder  presen- 
tations, pains  should  be  taken  to 
ascertain  whether  the  child  is  liv- 
ing before  performing  version. 
This  can  at  times  be  accomplished 
by  passing  the  hand  upward  near 
the  shoulder  and  feeling  for  pul- 
sations of  the  cord.  In  all  ex- 
treme cases,  the  continued  retrac- 
tion of  the  uterus,  by  limiting  the  placental  area,  is  apt  to  produce 
fetal  asphyxia.  If  the  child  is  living,  the  conditions  are  usually  such 
that  version  can  still  be  performed,  provided  care  be  taken  at  the  same 
time  to  press  the  head  from  without  toward  the  uterine  axis.  Exces- 
sive distention  of  the  cervix  develops  much  more  slowly  in  primiparae 
than  in  women  who  have  had  previous  confinements.  If  the  child  is 
dead,  or  where  version  is  impracticable,  decapitation  should  be  em- 
ployed to  release  the  patient  from  further  danger. 

Treatment  after  the  Occurrence  of  Rupture.— If  rupture  is  suspected 
to  have  taken  place,  the  child  should  be  delivered  without  delay.  The 
means  of  delivery  should  be  selected  with  the  view  to  enlarge  the 
opening  as  little  as  possible.    In  vertex  presentations,  if  the  diagnosis 


Fig. 


224. — Eetraction  in 


case  of  shoulder 


presentation.  (Bandl.) 


572 


THE  PATHOLOGY  OF  LABOR. 


is  clear,  it  is  advisable  to  perforate  and  extract  with  the  cranio- 
clast,  as  the  child  is  rarely  born  alive  where  rupture  has  taken 
place. 

If  the  head  has  passed  through  the  rent,  if  the  os  is  dilated,  and  if 
the  feet  are  felt  near  the  pelvic  brim,  the  withdrawal  of  the  child  by 
version  is  usually  effected  without  difficulty.  If,  however,  the  cervix 
is  rigid,  or  if  so  large  a  portion  of  the  foetus  has  passed  into  the  peri- 
toneal cavity  that  its  withdrawal  is  liable  to  increase  the  size  of  the 
laceration,  it  is  doubtless  better  to  incise  the  abdomen  at  the  linea 
alba,  and  deliver  through  the  artificial  opening.  Indeed,  it  is  a  ques- 
tion whether  it  is  not  wise  to  perform  gastrotomy  in  all  cases  of  com- 
plete rupture,  even  where  delivery  by  the  natural  j)assages  has  been 
accomplished,  provided  the  rent  does  not  close  with  the  contraction  of 
the  emptied  uterus.  It  may  be  fairly  stated  that  an  extensive  internal 
haemorrhage  is  necessarily  followed  by  the  death  of  the  patient.  As, 
however,  complete  rupture  is  almost  inevitably  followed  by  the  intra- 
peritoneal effusion  of  blood,  the  patient's  condition  is  thereby  rendered 
extremely  desjierate.  Gastrotomy  in  such  cases  enables  the  operator 
to  cleanse  the  abdominal  cavity,  and,  if  necessary,  to  introduce  sutures 
as  a  means  of  preventing  further  bleeding  from  the  uterine  wound. 
The  results  of  gastrotomies  performed  for  the  removal  of  the  child 
after  its  escape  into  the  abdomen  are  extremely  encouraging — Trask's 
statistics  showing  76  per  cent,  of  recoveries,  those  of  Jolly  69  per 
cent.,  and  the  United  States  statistics,  collected  with  indefatigable 
zeal  by  Harris,  53^^  per  cent.  In  the  autopsies  I  have  witnessed 
upon  women  who  have  died  from  rupture  after  delivery  by  the  nat- 
ural passages,  it  has  always  seemed  to  me  that  a  timely  gastrotomy, 
performed  before  peritonitis  had  set  in,  would  have  afforded  a  good 
chance  of  saving  the  patient's  life. 

In  cases  where  the  rupture  is  incomplete,  or  where  the  uncertainty 
as  to  the  extent  of  the  lesion  leads  the  physician  to  shrink  from  ab- 
dominal section,  clots  in  the  vicinity  of  the  opening  should  be  removed 
with  the  hand,  firm  contractions  should  be  excited,  and  the  uterus 
should  be  fixed  in  position  by  means  of  a  bandage  and  pads  of  cotton, 
and  dry  cold,  to  restrain  haemorrhage  and  prevent  peritonitis,  should 
be  kept  continuously  applied  to  the  abdomen.  At  the  same  time  the 
usual  remedies  against  shock  and  collapse  should  be  administered, 
according  to  the  necessities  of  the  patient. 

As  the  uterine  opening  has  a  tendency  to  speedily  close,  and  as 
death,  when  not  due  to  shock  or  loss  of  blood,  is  most  frequently  the 
result  of  the  septic  decomposition  of  retained  fluids,  a  priori  drainage 
ought  to  prove  an  essential  aid  to  treatment.  Recent  successes 
tlirough  its  instrumentality  have  been  reported  by  Frommcl,*  Mos- 

*  Frommel,  "  Zur  Actiologie  und  Therapie  der  Uterusruptur,"  "  Ztschr.  f.  Geburtsh. 
und  Gjnaek,,"  Bd.  v,  Heft  2. 


RUPTURES  OF  THE  GENITAL  CANAL. 


573 


bach,  Graefe,  and  Felsenreich.  *  The  plan  recommended  by  the  latter, 
based  upon  the  experience  of  Gustav  Braun's  clinic,  consists  in  tak- 
ing a  large-sized  piece  of  drainage  tubing,  and  bending  it  in  the  mid- 
dle so  as  to  leave  the  extremities  of  equal  length.  A  large  opening 
should  then  be  made  at  the  arch,  which  is  to  be  introduced  through  the 
point  of  rupture,  and  the  descending  branches  of  the  tube  should  be 
fastened  together  to  prevent  the  formation  of  a  bridge  of  tissue  be- 
tween them  during  the  process  of  healing.  The  upper  end  of  the 
drainage  apparatus  should  be  passed  from  a  half -inch  to  an  inch  be- 
yond the  torn  borders  of  the  uterine  wound,  and  the  lower  ends 
stitched  with  silk  to  the  posterior  commissure.  Over  the  vulva  and 
the  apparatus  there  should  be  placed  antiseptic  cotton,  which  should 
be  changed  several  times  daily.  After  the  first  forty-eight  hours,  by 
which  time  it  may  be  assumed  that  protective  adhesions  will  have 
formed  in  the  neighborhood,  a  regular  irrigation  of  the  wound  with  a 
two-per-cent.  solution  of  carbolic  acid  should  be  carried  out,  with  a 
view  to  prevent  a  septic  poisoning  from  the  decomposition  of  the  pus 
and  the  lochia. 

Rupture  limited  to  the  Peritoneal  Covering  of  the  Uterus. — This 
very  rare  form  requires  but  brief  mention.  In  all,  but  ten  cases  have 
been  reported.  It  occurs  under  apparently  normal  conditions,  with- 
out premonitory  symptoms.  It  is  supposed  to  be  due  to  deficient 
elasticity  of  the  peritonaeum,  and  may  take  place  during  either  preg- 
nancy or  labor.  Death  in  the  known  cases  resulted  from  internal 
hajmorrhage,  from  peritonitis,  or  from  shock  (Spiegelberg). 

Perforation  from  Pressure. — In  studying  the  influence  of  the  con- 
tracted pelvis,  we  have  already  had  occasion  to  consider  the  origin  of 
circumscribed  losses  of  substance  in  the  uterus  due  to  the  pressure  of 
the  pelvic  walls.  In  the  present  connection  it  is  only  necessary  to 
state  that  they  are  more  frequently  followed  by  recovery  than  the 
ruptures,  in  favorable  cases  exudation  closing  the  opening,  and  the 
necrosed  tissue  passing  away  through  the  vagina. 

Lacerations  of  the  Vaginal  Portion  of  the  Cervix.— Lacerations  at 
the  OS  externum  of  moderate  extent  are  the  nearly  constant  concomi- 
tant of  physiological  labor.  The  ^^show"  of  monthly  nurses  consists 
of  mucus  tinged  with  blood  furnished  from  the  slight  tears  which  are 
produced  during  the  passage  of  the  head  througvh  the  cervical  orifice. 
At  times,  however,  these  lacerations  may  assume  a  pathological  im- 
portance, reaching  upward  to  the  vaginal  junction,  or  even,  in  extreme 
cases,  stretching  outward  through  the  upper  portion  of  the  vagina. 
At  the  time  of  their  occurrence,  they  give  rise  to  no  special  symptoms. 
After  the  birth  of  the  child,  they  may  become  the  source  of  post-par- 
turn  haemorrhage,  or  they  may  interfere  with  involution,  and  during 

*  Felsenreich,  '*  Beitrag  zur  Therapie  der  Uterusruptur,"  "  Arch,  f .  Gynaek.,"  Bd. 
xvii,  Heft  3. 


574 


THE  PATHOLOGY  OF  LABOR. 


childbed  expose  the  patient  to  the  risks  of  infection.  In  after-life 
they  furnish  the  foundation  of  a  multitude  of  uterine  disorders  (Em- 
met). They  occur  most  frequently  in  primiparse,  especially  elderly 
ones ;  in  oedema  of  the  cervix  ;  in  cases  where  the  anterior  lip,  pushed 
downward  by  the  occiput,  is  caught  between  the  head  and  the  pubic 
walls,  and  thus  is  prevented  from  retracting  simultaneously  with  the 
posterior  lip  ;  and  as  a  consequence  of  obstetrical  operations.  Severe 
lacerations  extending  above  the  vaginal  junction  are  most  frequently 
produced  in  pelvic  deliveries,  where  the  head  is  extracted  by  force 
through  an  imperfectly  dilated  os. 

Most  commonly  these  lacerations  follow  a  longitudinal  direction. 
In  rare  cases,  where  there  is  extreme  rigidity  of  the  os  externum,  or 
where,  after  the  escape  of  the  amniotic  fluid,  the  head  distends  the  an- 
terior lip  without  pressing  upon  the  os,  a  transverse  rent  may  occur 
through  which  the  child  may  pass.  Sometimes  a  longitudinal  tear 
may  be  combined  with  one  running  transversely,  the  lip  then  hanging 
by  a  pedicle  to  the  uterus,  or  the  entire  lip  may  be  torn  off.  Isolated 
cases  of  so-called  annular  laceration  have  been  reported,  where  the 
transverse  rent  has  extended  through  the  whole  vaginal  portion,  so 
that  the  lower  segment  has  been  detached  in  the  form  of  a  ring. 

In  addition  to  the  ordinary  principles  which  should  govern  the 
management  of  every  labor,  Bandl  lays  great  stress  upon  the  pushing 
up  of  the  confined  anterior  lip  as  an  important  prophylactic  measure. 

Haemorrhage  due  to  cervical  laceration  should  be  controlled  by 
cold-water  injections,  by  plugs  of  cotton  steeped  in  the  solution  of  the 
persulphate  of  iron  and  applied  through  the  speculum  directly  to  the 
bleeding  point,  or,  still  better,  by  closing  the  rent  with  silver  sutures. 
The  latter  plan,  which  appears  to  have  been  first  successfully  tried  by 
Professor  Montrose  A.  Fallen,*  has  of  late  years  come  into  general 
favor.  In  view  of  the  bad  light  by  which  the  operation  has  usually 
to  be  performed,  the  suggestion  of  Schroeder,  to  draw  the  cervix  with 
the  volsella  forceps  outside  the  vulva,  while  an  assistant  j^ushes  the 
uterus  down  into  the  pelvis  from  above,  is  worthy  of  being  borne  in 
mind.  With  the  wounded  parts  thus  exposed,  moreover,  the  repara- 
tive operation  advocated  presents  scarcely  appreciable  difficulties  to 
even  the  least  surgical  of  attendants. 

If  no  haemorrhage  occurs,  cervical  lacerations  are  rarely  recognized 
except  by  physicians  who  take  pains  to  invariably  investigate  the 
post-partum  condition  of  every  patient.  As  a  rule,  they  heal  rapidly 
during  involution.  Perfect  cleanliness,  maintained  by  the  free  use  of 
carbolized  washes,  promotes  the  healing  process,  and  is  a  safeguard 
against  the  inflammations  of  the  contiguous  connective  tissue  and  peri- 
tonaeum which  arise  from  infection. 

*  Fallen,  "  Accidents  of  Parturition  requiring  Surgical  Treatment,"  "  Richmond  and 
Louisville  Med.  Jour.,"  May,  1874. 


RUPTURES  OF  THE  GENITAL  CANAL. 


575 


Lacerations  of  the  Vagina. — Vaginal  lacerations  vary  in  gravity- 
according  to  their  extent  and  position.  In  the  upper  part  of  the  canal 
they  are,  as  a  rule,  continuous  with  ruptures  begun  in  the  uterus 
or  in  the  vaginal  portion.  In  contracted  pelves,  where,  owing  to 
excessive  retraction,  the  head  fills  the  vagina  without  entering  the 
pelvic  brim,  isolated  lacerations  of  the  vagina  may  follow  the  same 
general  causes  as  those  which  give  rise  to  rupture  of  the  uterus.  Per- 
haps the  most  common  vaginal  lesion  is  that  produced  by  the  un- 
guarded blades  of  the  forceps  when  applied  diagonally  in  place  of 
directly  to  the  sides  of  the  child's  head. 

In  most  cases  these  lacerations  heal  speedily  without  serious  symp- 
toms, provided  cleanliness  be  maintained  from  the  first.  Lacerations 
of  the  fornix  only  are  of  great  importance  on  account  of  their  proxim- 
ity to  the  peritonaeum,  and  because  of  the  exposure  of  the  parametri- 
um to  septic  absorption.  The  immediate  closure,  therefore,  of  these 
rents  with  silver  sutures  ought  to  be  attempted.  Owing  to  the  laxity 
of  the  tissues,  the  difficulties  of  reaching  the  wound  are  not  excessive, 
while  the  dangers  to  be  forestalled  are  of  a  peculiarly  threatening 
character. 

The  origin  and  nature  of  fistulous  communications  with  the  blad- 
der and  the  rectum  have  already  been  considered  in  connection  with 
the  pathology  of  labor.  Eesulting  for  the  most  part  from  necrosis 
due  to  pressure,  they  are  rarely  the  immediate  sequelae  of  childbirth, 
the  sloughing  of  the  dead  tissue  taking  place  during  the  course  of  the 
puerperal  period.  The  treatment  in  such  cases  belongs  properly  to 
the  domain  of  gynaecology.  The  closure  by  suture  is  only  available  as 
a  plan  of  treatment  in  cases  where  complete  laceration  through  the 
tissues  into  the  neighboring  organs  takes  place  during  labor,  as  the 
consequence  of  rudely  performed  obstetrical  operations. 

Lacerations  at  the  Vaginal  Orifice. — Owing  to  the  small  size  of  the 
vaginal  orifice,  tears  through  the  mucous  membrane  and  erosions  of 
the  vulva,  and,  in  primiparae,  the  rupture  of  the  frenulum,  are  to  be 
accounted  as  the  almost  inevitable  consequences  of  childbirth.  They 
are  the  principal  cause  of  the  external  soreness  experienced  after  labor. 
In  healthy  localities  they  heal  rapidly,  and  are  of  but  trivial  impor- 
tance. The  healing  process  is,  even  in  simple  cases,  promoted  by  the 
use  of  warm  disinfectant  douches.  Of  greater  moment  are  deep  peri- 
neal lacerations  and  those  of  the  vestibulum. 

Lacerations  of  the  Vestibulum. — Tears  limited  to  the  mucous  mem- 
brane are  usually  found  after  labor  at  the  sides  of  the  clitoris.  In 
exceptional  cases  these  tears  may  involve  the  underlying  erectile  tissue 
(bulbs  of  the  vestibule),  and  become  the  source  of  profuse  or,  when 
overlooked,  even  of  fatal  haemorrhage.  The  blood,  which  may  be 
either  venous,  arterial,  or  of  mixed  origin,  spurts  in  jets,  or  oozes  as 
from  a  soaked  sponge.    The  recognition  of  the  lesion  is  easy  upon 


576 


THE  PATHOLOGY  OF  LABOR. 


inspection.  It  should  always  be  tlionght  of  as  a  possible  cause  of  post- 
partum haemorrhage  in  every  case  where  the  flow  continues  after  the 
contraction  of  the  uterus. 

The  bleeding  may  be  temporarily  arrested  by  the  pressure  of  the 
finger  until  the  expulsion  of  the  placenta.  Ligatures  to  the  bleeding 
vessels,  owing  to  the  complexity  of  the  structures,  are  of  no  avail. 
In  slight  cases  a  stream  of  cold  water  is  a  sufficient  haemostatic.  In 
others,  the  bleeding  requires  to  be  checked  by  one  or  two  deep  sutures 
introduced  so  as  to  bring  the  torn  surfaces  into  apposition.  If  the 
bleeding  appears  to  come  from  one  or  two  points,  the  pinces  hemosta- 
tiques  are  of  service.  Styptics  and  astringents  are  usually  effective, 
but  they  possess  the  drawback  of  augmenting  the  pain  and  soreness. 

Lacerations  of  the  Peringeuin. — In  the  chapter  upon  the  ''Manage- 
ment of  Normal  Labor,"  the  nature,  origin,  and  prevention  of  perineal 
lacerations  have  already  been  considered.  The  diagnosis  is  made  by  a 
careful  inspection  of  the  genital  organs  after  delivery.  The  extent  of 
the  lesion  is  estimated  by  including  the  recto-vaginal  septum  between 
the  thumb  and  index-finger. 

The  treatment  of  perineal  laceration  consists  either  in  keeping  the 
woman  in  bed  until  the  wounded  surfaces  cicatrize,  or  in  bringing  the 
parts  into  apposition  by  means  of  sutures,  with  the  intent  to  secure 
primary  union.  The  first  plan  is  sufficient,  if  the  wound  be  of  slight 
extent.  If,  however,  the  rupture  extends  to  the  sphincter  ani,  and 
involves  the  entire  perineal  body,  the  vagina  is  left  without  support, 
rectocele  or  cystocele  ensues,  the  uterus  sinks  downward  and  becomes 
displaced  backward,  and  in  the  end  prolapsus  is  apt  to  result.  If  the 
sphincter  ani  and  the  recto-vaginal  wall  are  involved,  inability  to  re- 
strain the  bowels  adds  to  the  discomfort  of  the  patient.  This  sequence 
of  symptoms,  so  familiar  to  gynaecologists,  forms  an  urgent  plea  for 
the  resort  to  surgical  means  to  repair  the  injury.  Only  a  very  credu- 
lous person  really  believes  that  he  has  witnessed  union  by  first  inten- 
tion in  extensive  ruptures,  as  the  result  of  tying  the  knees  together 
and  enjoining  rest  upon  the  side.  The  action  of  the  transversi-peri- 
naei  muscles  tends  to  draw  the  torn  surfaces  apart.  Moreover,  the 
necessity  of  separating  the  knees  in  passing  urine,  and  to  enable  the 
nurse  to  cleanse  the  genitalia,  makes  it  impossible  to  keep  them  in 
contact  for  any  lengthened  period. 

To  the  immediate  operation  there  is  no  valid  objection.  It  is  not 
difficult,  it  is  not  extremely  painful,  and  its  performance,  as  a  rule, 
diminishes  the  risks  of  infection  and  shortens  the  puerperal  period. 
It  is  true  that  the  object  aimed  at  may  not  be  attained.  In  private 
practice,  however,  failure  is  the  exception.  The  argument  that  the 
operation  is  in  itself  a  confession  does  not  deserve  discussion. 

For  its  performance  the  patient  should  lie  upon  her  back,  with  her 
hips  well  over  the  edge  of  the  bed.    Two  assistants  to  hold  the  knees 


RUPTUKES  OF  THE  GENITAL  CANAL. 


677 


are  of  great  convenience.  In  operations  requiring  the  introduction  of 
not  more  than  three  or  four  sutures,  anaesthesia  may  be  dispensed 
with.  In  lengthy  operations,  such  as  are  necessitated  by  lacerations 
extending  up  the  posterior  vaginal  wall,  ether  should  be  given  in  place 
of  chloroform,  and  its  administration  should  be  intrusted  to  an  experi- 
enced person  only.  It  can  not  be  too  often  repeated  that  anaesthesia 
after  labor  calls  for  the  exercise  of  extreme  caution. 

The  wound  should  be  prepared  by  carefully  washing  away  blood 
and  clots  with  warm  carbolized  water,  and  by  removing  shreddy  por- 
tions with  scissors.  For  lacerations  not  extending  through  the  sphinc- 
ter ani  I  use  Peaslee's  needle,  which  is  furnished  with  an  eye  at  the 
point,  and  is  set  in  a  wooden  handle.  It  possesses  the  advantage  of 
strength,  a  quality  of  no  mean  importance  in  making  the  circuit  of 
the  redundant  tissues  with  which  we  have  to  deal  after  labor.  I  use 
the  silver  suture,  and  after  repeated  trials  have  not  been  able  to  con- 
vince myself  that  it  can  be  equally  well  replaced  by  silk. 

The  first  suture  should  be  passed  just  in  front  of  the  anus.  It 
should  be  entered  and  brought  out  about  a  half-inch  from  the  rupt- 
ured borders.  The  others  should  follow  at  from  one  third  to  one  half 
inch  intervals.  Each  suture  should  make  the  entire  circuit  of  the 
wound.  This  can  be  readily  accomplished  by  guiding  the  point  of 
the  needle  through  the  residue  of  the  perineal  body  with  two  fingers 
in  the  anus  and  with  the  thumb  upon  the  vaginal  surface.  To  secure 
a  stronger  hold  for  the  last  suture,  the  needle  should  be  made  to  enter 
the  vagina  above  the  upper  angle  of  the  rent,  and  the  wire  should  be 
made  to  traverse  a  portion  of  undenuded  tissue  before  completing  the 
circuit.  In  closing  the  wound,  great  pains  must  be  taken  not  to  twist 
the  sutures  too  tightly,  as  in  that  case  they  are  apt  either  to  cut  out 
or  to  produce  sloughing. 

Sometimes,  in  rents  extending  through  the  sphincter  ani  and  the 
recto-vaginal  septum,  the  simple  perineal  sutures  will  effect  a  satisfac- 
tory union.  Thus,  in  a  patient  at  the  Emergency  Hospital,  with  a 
laceration  extending  nearly  to  the  cervix,  and  whose  condition  pre- 
cluded a  lengthy  operation,  I  obtained  an  excellent  result  by  passing  a 
single  wire  above  the  angle  of  the  wound,  and  twisting  the  ends  out- 
side the  perinaeum.  As  a  rule,  however,  it  is  desirable  to  adjust  the 
edges  with  great  care,  first  closing  the  rent  upon  the  rectal  side,  then 
bringing  together  the  split  in  the  mucous  membrane  upon  the  vaginal 
side  with  transverse  sutures,  and  finally  bringing  the  lower  borders  of 
the  perinaeum  together  by  a  separate  operation.  This  disposition  is 
the  so-called  triangular  suture  of  Simon.*  It  requires  fine  needles,  a 
needle-holder,  an  adjuster,  a  wire-twister,  and,  in  fact,  all  the  para- 
phernalia of  the  gynaecologist.    The  length  of  the  operation  renders 

*  Vide  Garrigues's  excellent  paper  entitled  "  The  Obstetric  Treatment  of  the  Peri- 
naeum,"  "Am.  Jour,  of  Obstet.,"  April,  1880. 
37 


578 


THE  PATHOLOGY  OF  LABOR. 


necessary  an  anaesthetic,  which  should  be  ether  rather  than  chloro- 
form. The  disgusting  condition  of  a  patient  with  laceration  through 
the  recto-vaginal  septum,  where  the  healing  process  has  been  the  re- 
sult of  granulation,  justifies  the  attempt  to  secure  immediate  union. 

The  requirements  in  the  way  of  after-treatment  are  very  simj^le. 
The  urine  should  be  drawn  every  four  to  six  hours  with  a  catheter, 
until  the  patient  is  able  to  pass  her  water  spontaneously  ;  the  bowels 
should  be  kept  open  with  salines  ;  and  the  knees  should  be  tied  loose- 
ly, to  remind  the  woman  of  the  desirability  of  keeping  them  in  con- 
tact. A  little  opium  may  be  given,  if  the  pain  experienced  is  consid- 
erable. Pain  in  childbed  from  any  cause  helps  to  depress  the  vitality. 
The  perineal  sutures  should  be  left  a  week  in  situ.  Many  promising 
cases  are  spoiled  by  removing  the  sutures  too  early.  The  vaginal 
sutures  may  be  allowed  to  remain  until  the  external  union  is  suffi- 
ciently solid  to  permit  the  introduction  of  the  speculum.  Cat-gut 
sutures  for  the  rectum  are  to  be  preferred  when  they  can  be  obtained, 
as  they  obviate  the  necessity  of  future  removal. 

For  the  more  superficial  lacerations  of  the  perinaeum  the  serres 
fines  invented  by  Vidal  de  Cassis,  and  extensively  used  in  Vienna,  have 
been  warmly  advocated  in  this  country  by  Professor  M.  D.  Mann,* 
and  by  Garrigues.f  My  own  experience  with  them  has  not  been  fort- 
unate, but  the  better  results  from  their  use  in  the  hands  of  their  sup- 
porters recommend  them  to  trial. 

Thrombus  of  the  Vagina  and  Vulva. — Haemorrhagic  effusions  into 
the  external  organs  of  generation  occur  with  greatest  frequency  in  the 
labia  majora,  more  rarely  in  the  labia  minora,  and  occasionally  be- 
tween the  superficial  and  median  fasciae  of  the  perinaeum.  These 
extravasations  may  form  tumors  beneath  the  subcutaneous  or  submu- 
cous tissues  of  the  vulva  or  vagina,  which  vary  in  size  from  that  of  a 
hen's  egg  to  that  of  a  child's  head.  As  a  rule,  the  blood  is  poured 
out  into  the  cellular  tissue  seated  below  the  diaphragm  of  the  pelvis. 
The  extravasation  may,  however,  stretch  upward  along  the  vagina  to 
the  cellular  tissue  of  the  uterus,  then  posteriorly  beneath  the  perito- 
naeum to  the  kidneys,  and  around  in  front  to  the  navel  and  laterally 
to  the  iliac  fossae  (Winckel).  The  source  of  the  haemorrhage  may  be 
venous  or  arterial.  The  vessel  from  which  the  haemorrhage  takes 
place  is  usually  situated  in  the  lower  portion  of  the  vagina ;  in  less 
frequent  cases,  in  the  vulva. 

Symptoms. — The  first  sensation  experienced  at  the  time  of  the 
rupture  is  usually  one  of  intense  pain,  proportioned  to  the  size  of  the 
tumor  and  the  rapidity  of  its  formation,  though  in  a  case  witnessed 
by  Professor  Barker  |  this  symptom  was  absent.    As  the  effusion  con- 

*  Mann,  "  The  Lnmediate  Treatment  of  Superficial  Rupture  of  the  Perinaeum,"  "Am. 
Jour,  of  Obstet.,"  November,  1874. 

•)•  Garrigues,  loc.  cit.  X  Barker,  "  Puerperal  Diseases,"  p.  58. 


RUPTURES  OF  THE  GENITAL  CANAL. 


579 


tinues,  swelling  of  the  vulva,  usually  upon  one  side,  results,  and  the 
skin  becomes  blue  and  nearly  translucent.  The  patient  complains 
of  pain,  and  feels  faint,  while  her  lips  and  cheeks  grow  white.  If 
the  sac  contains  fluid  blood,  fluctuation  is  detected  ;  after  coagula- 
tion the  tumor  has  a  soft,  boggy  feel.  If  the  tension  increases,  the 
skin  may  yield,  the  blood  and  coagula  escape,  and,  if  no  means  be 
adopted  to  arrest  the  haemorrhage,  the  patient  may  die  in  a  few  min- 
utes from  acute  anaemia. 

If  the  thrombus  be  of  small  size  and  situated  low  down,  the  after- 
symptoms  may  be  of  slight  importance.  The  fluid  may  be  absorbed, 
the  walls  of  the  cavity  unite,  and  the  tumor  disappear  entirely. 
Tumors  of  larger  size  produce  symptoms  referable  to  pressure,  such  as 
back-ache,  rectal  obstruction,  and  ischuria.  The  vagina  may  be  so 
narrowed  as  scarcely  to  permit  the  passage  of  the  finger.  Eupture,  if 
not  immediate,  usually  occurs  spontaneously  in  the  course  of  a  few 
days,  and  is,  as  a  rule,  preceded  by  necrosis  of  a  portion  of  the  de- 
tached mucous  membrane.  The  most  frequent  point  of  spontaneous 
rupture  is  at  the  junction  of  the  larger  and  smaller  labium.  If  the 
necrosed  tissues  become  gangrenous,  death  from  septicaemia  may  result. 
Winckel*  sums  up  the  various  terminations  of  thrombus  as  follows  : 
1.  Death  from  haemorrhage,  with  or  without  precedent  rupture  ;  2. 
Death  from  decomposition  of  the  sac-contents,  with  consecutive  sep- 
ticaemia or  septico-pyaemia,  most  frequently  after  rupture  or  opening 
of  the  sac  ;  3.  Rupture  and  recovery ;  4.  Eupture,  with  formation  of 
fistulae  ;  5.  Absorption  without  rupture,  follow^ed  by  recovery. 

Diagnosis. — The  diagnosis  is  simple.  The  rapid  development  and 
increase  of  the  tumor,  its  bluish  color,  its  elastic  or  fluctuating  char- 
acter, the  sharp  pain,  and  the  acute  anaemia,  occurring  independently 
of  uterine  haemorrhage,  sufficiently  point  to  a  sanguineous  effusion 
into  the  subcutaneous  cellular  tissue.  The  extent  of  the  tumor  must 
be  determined  by  rectal  and  vaginal  exploration.  It  is  only  at  the 
beginning  that  it  will  be  found  possible  to  ascertain  the  seat  of  the 
haemorrhage,  whether  in  the  vulva,  vagina,  or  perinaeum.  Sometimes, 
after  rupture  and  the  discharge  of  the  clots,  the  bleeding  vessel  may 
be  detected. 

Etiology. — The  formation  of  the  thrombous  tumor,  with  rare  excep- 
tions, takes  place  during  or  shortly  after  labor.  If  the  vessel  rupture 
in  advance  of  the  presenting  part,  the  effusion  may  be  immediate  and 
furnish  an  obstacle  to  delivery,  or  the  descent  of  the  foetus  may  check 
the  haemorrhage  for  a  time,  to  break  out  afresh  after  the  labor  is  ended. 
In  rupture  due  to  necrosis  consequent  upon  pressure,  the  haemorrhage 
does  not,  of  course,  take  place  until  sloughing  occurs.  Eupture  may 
follow  excessive  straining,  rapid  dilatation  of  the  genital  canal,  or 
direct  injuries.    A  varicose  condition  of  the  veins  does  not,  as  would 

*  WiNCKEL,  "Die  Pathologie  und  Therapie  dcs  Wochcnbetts,"  2te  Auflagc,  p.  132. 


580 


THE  PATHOLOGY  OF  LABOR. 


naturally  be  inferred,  especially  predispose  to  the  occurrence  of  the 
accident.  Thus,  it  was  present  in  but  six  of  the  fifty  cases  collected 
by  Winckel. 

Prognosis. — The  prognosis  of  vaginal  thrombus  is  serious.  Deneux 
reported  twenty- two  deaths  in  sixty  cases,  a  mortality  evidently  ex- 
cessive ;  Winckel  reported  six  deaths  in  fifty  cases ;  Barker  reported 
two  deaths  in  twenty-two  cases ;  and  Scanzoni  one  death  in  fifteen 
cases.  But  statistics  like  these  are  apt  to  give  rise  to  a  misleading  im- 
pression. A  thrombus  jper  se  is  rarely  a  dangerous  complication.  It 
may,  however,  become  so  either  because  after  rupture  no  means  are 
adopted  to  limit  the  amount  of  haemorrhage,  or  because,  in  unhealthy 
localities,  the  tense  membrane  covering  the  tumor  is  liable  to  become 
gangrenous,  and  the  vast  vaginal  wound  furnishes  at  once  a  congenial 
soil  for  the  multiplication  of  septic  germs,  and  an  absorbent  surface 
by  which  the  septic  poison  generated  is  afforded  a  ready  entry  into 
the  adjacent  cellular  tissue.  Thus,  Barker  reports  nine  cases  in  private 
practice,  in  all  of  which  the  patients  recovered.  Of  thirteen  cases  in 
hospital  practice,  two  patients  died  of  puerperal  fcA^r.  The  progno- 
sis is  likewise  less  favorable  in  cases  where  there  exists  at  the  same 
time  extensive  separation  of  the  peritonaeum. 

Treatment. — The  conditions  of  successful  treatment  are,  restriction 
of  the  haemorrhage  and  the  j)i'evention  of  septicaemia.  Early  recog- 
nition of  the  accident  is  very  desirable. 

So  soon  as  effusion  is  recognized  the  forceps  should  be  applied,  and 
the  head  should  be  extracted  as  speedily  as  is  consistent  with  the 
preservation  of  the  integrity  of  the  maternal  tissues.  To  quote  from 
Professor  Barker's  excellent  treatise  :  The  exciting  cause  of  the  ac- 
cident is  the  arrest  of  the  circulation  by  the  mechanical  pressure  of 
the  presenting  part  of  the  foetus.  The  sooner  the  pressure  is  removed 
the  sooner  the  danger  will  be  over,  and  the  less  will  be  the  injury  to 
the  parts."  Moreover,  as  we  have  seen,  the  head  in  its  descent  acts  as 
a  tampon,  by  means  of  which  the  haemorrhage,  whether  external  or  in 
the  submucous  tissue,  is  temporarily  held  in  check.  If  the  tumor 
in  advance  of  the  head  is  so  large  that  the  delivery  can  not  be  accom- 
plished without  impairing  the  vitality  of  the  sac-walls,  the  danger 
should  be  averted  by  incising  the  thrombus  and  turning  out  the 
coagula. 

Haemorrhage  after  the  birth  of  the  child  is  apt  to  be  very  profuse, 
especially  if  the  sac  has  been  opened  either  by  spontaneous  rupture  of 
its  coverings  or  with  the  knife.  So  long  as  the  sac-walls  are  intact,  the 
pent-up  blood  exercises  a  considerable  pressure  upon  the  bleeding  ves- 
sel. For  this  reason  it  is  well  to  cover  an  opening,  if  one  happens  to 
have  formed,  with  lint  soaked  in  a  solution  of  one  of  the  per-salts  of 
iron.  The  continuance  of  internal  haemorrhage  should  then  be  checked 
by  means  of  a  water-bag  (a  large  Barnes  dilator  will  suffice)  intro- 


RUPTURES  OF  THE  GENITAL  CANAL. 


581 


duced  into  the  vagina  and  distended  with  ice-water.  The  hydrostatic 
pressure  rarely  requires  to  be  maintained  for  longer  than  half  a  day, 
during  which  time  it  should  be  repeatedly  removed  for  a  few  moments 
to  allow  the  vagina  to  bo  cleansed  by  disinfectant  injections.  The 
urine  should  be  drawn  with  a  catheter  during  the  first  forty-eight 
hours,  as  every  straining  efiort  is  to  be  carefully  guarded  against.  A 
tampon  of  linen  rags,  or  of  cotton,  is  inadmissible  on  account  of  the 
tendency  it  possesses  to  excite  rapid  decomposition  in  the  lochial  dis- 
charges. Immediate  opening  of  the  thrombus,  followed  by  emptying 
the  sac,  and  filling  the  cavity  with  lint  soaked  in  astringent  solutions, 
are  measures  which  should,  on  account  of  the  suppuration  likely  to  be 
thereby  excited,  be  reserved  for  cases  where  milder  procedures  have 
proved  ineffective. 

The  ultimate  opening  of  the  sac,  after  the  haemorrhage  has  once 
been  arrested,  is  rarely  to  be  avoided.  Still  cases  are  on  record  where 
tumors  the  size  of  a  man's  fist  have  disappeared  by  absorption.  As 
this  is  the  most  favorable  mode  of  termination,  every  effort  should  be 
made  to  secure  such  a  result.  To  this  end  quiet  should  be  enjoined, 
cold  should  be  employed,  and  pain  should  be  subdued  by  opiates.  If, 
however,  the  tumor  increases  in  size,  the  skin  becomes  greatly  discol- 
ored, and  vesicles  form  upon  its  surface,  it  is  better  to  anticipate 
threatened  gangrene  or  rupture  by  incision.  If  the  circumstances  per- 
mit of  delay,  it  is  better  to  wait  three  to  four  days  to  make  sure  of  the 
stoppage  of  bleeding.  The  best  point  for  laying  open  the  tumor  is 
upon  the  inner  surface  of  the  labium  majus.  The  incision  should  be 
two  to  three  inches  in  length.  In  the  subsequent  treatment  of  the 
cavity,  disinfection  should  be  scrupulously  practiced. 

Rupture  of  the  Pelvic  Articulations.* — Rupture  of  the  pelvic  artic- 
ulations may  take  place  spontaneously  where  either  inflammation  or 
excessive  relaxation  of  the  joints  exists  at  the  time  of  labor.  More 
commonly  it  is  the  result  of  difficult  forceps  operations  performed  in 
cases  of  contracted  pelves.  The  risk  of  the  occurrence  of  this  accident 
is  especially  great  when  the  forceps  is  applied  to  the  head  at  the  brim 
and  forcible  tractions  are  made  in  a  direction  anterior  to  the  pelvic 
axis. 

The  symphysis  is  the  articulation  which  is  principally  exposed  to 
this  form  of  injury,  though  it  is  obvious  that  no  increase  in  the  capaci- 
ty of  the  pelvis  consequent  upon  the  separation  of  the  symphysis  is 
possible  without  simultaneous  rupture  of  at  least  one  of  the  sacro-iliac 
synchondroses.  At  the  symphysis  the  rupture  is  apt  to  be  complete, 
at  the  synchondroses  the  rupture  is  usually  confined  to  the  anterior 
surface.    It  may  take  place  in  the  median  line,  or  upon  the  side,  be- 

*  Ahlfeld,  "  Die  Verletzungen  der  Beckengelenke  wahrend  d.  Gcburt  und  im  Wo- 
chenbett,"  Schmidt's  "  Jahrbucher,"  Bd.  169,  1876,  p.  185;  Spiegelberg,  "  Lehrbuch," 
p.  636. 


582 


THE  PATHOLOGY  OF  LABOR. 


tween  the  cartilage  and  the  pubic  bone.  If  the  injury  be  slight,  the 
synovial  cavity  of  the  symphysis  may  not  be  injured.  At  the  synchon- 
droses, opening  of  the  joint-cavity  is  inevitable.  An  excessive  degree 
of  the  lesion  is  accompanied  by  laceration  of  the  vagina,  the  bladder, 
and  the  intervening  connective  tissue. 

Occasionally  the  rupture  of  the  joint  is  announced  by  a  perceptible 
sound,  by  intense  jDain,  and,  as  the  result  of  the  increase  in  the  pelvic 
space,  by  rapid  advance  of  the  head.  In  the  lighter  forms,  however, 
which  make  up  the  bulk  of  the  cases  witnessed,  there  are  no  distinc- 
tive symptoms  at  the  time  of  the  accident.  The  pathognomonic  sec- 
ondary manifestations  are  outward  rotation  of  the  thighs,  and  local- 
ized pain  increased  by  movement  of  the  limbs,  and  relieved  by  fixation 
of  the  pelvis.  Objective  evidence  of  ruj^ture  at  the  symphysis  is 
afforded  by  the  movements  produced  at  the  articulation  by  alternate 
pressure  upon  the  ends  of  the  pubic  bones,  and  by  combined  internal 
and  external  examination.  If  the  rent  extends  to  the  vagina,  the 
laceration  may  be  detected  by  the  touch.  Separation  of  the  sacro-iliac 
synchondroses  is  rendered  probable  if  violent  pain  is  excited  by  alter- 
nately pressing  the  anterior  j)ortions  of  the  ilia  together  and  then 
drawing  them  apart  from  one  another.  Bladder  disturbances  are  rare  ex- 
cept in  cases  where  the  separation  at  the  symphysis  is  complete,  or  where 
the  rupture  is  followed  by  inflammation  and  the  formation  of  pus. 

The  treatment  consists  in  supporting  the  pelvis  by  means  of  a  suit- 
able bandage,  in  keeping  the  patient  upon  her  back,  and  in  maintain- 
ing strict  cleanliness.  The  bowels  should  for  a  time  be  kept  confined. 
As  regards  the  first  indication,  Spiegelberg  says  an  ordinary  towel 
properly  folded  and  fastened  at  the  pubes,  with  care  taken  to  avoid 
pressure  upon  the  crests  of  the  ilia,  will  answer  all  the  requirements. 
Eupture  of  the  pelvic  articulations,  when  not  complicated  by  other 
lesions,  or  by  puerperal  infection,  run  for  the  most  part  a  favorable 
course.  During  convalescence  the  patient  should  wear  some  form  of 
permanent  bandage,  such  as  has  been  recommended  in  cases  of  relaxa- 
tion of  the  pelvic  symphyses. 


CHAPTER  XXXIV. 

PROLAPSE   OF   THE  FUNIS,  ETC. 

Prolapsed  funis. — Asphyxia  neonatorum. — Collapse  and  sudden  death  during  labor  and 
childbed  from  thrombosis,  from  embolism,  and  from  entrance  of  air  into  the  circu- 
lation.— On  the  extraction  of  the  child  in  case  of  death  of  the  mother  in  preg- 
nancy or  labor. — Tympanites  uteri. 


When  the  cord  is  felt  within  the  membranes  next  to  the  j)resent- 
ing  part,  a  funis  presentation  is  said  to  exist.    After  the  membranes 


PROLAPSE  OF  THE  FUNIS,  ETC. 


583 


have  ruptured,  the  cord  descends  into  the  vagina,  in  front  of  the  pre- 
senting part,  and  is  then  said  to  be  prolapsed.  Generally  the  cord 
occupies  one  of  the  hollows  upon  the  sides  of  the  promontory ;  less 
frequently  it  descends  opposite  the  lateral  walls  of  the  pelvis  ;  the  site 
in  front  of  the  promontory  or  behind  the  pubes  is  very  exceptional. 

As  regards  the  frequency  of  the  accident,  the  experience  of  individ- 
uals varies  widely.  Churchill  collected  98,512  cases  of  labor,  in  which 
it  occurred  401  times,  or  in  the  proportion  of  one  to  245*5  cases.  Dr. 
Christisen,  of  Wyandotte,  Michigan,  met  with  it  23  times  in  1,516  cases. 
Meachem  met  with  it  10  times  in  931  cases.  Mr.  Bland  met  with  it, 
on  the  other  hand,  but  once  in  1,897  cases.* 

Prolapse  of  the  cord  occurs  only  in  cases  where  the  head  does  not 
completely  occlude  the  lower  uterine  segment.  It  is  favored  by  a  long 
cord,  by  a  deep  placental  site,  by  the  insertio  velamentosa,  by  oblique 
and  breech  presentations,  by  prolapse  of  the  extremities,  by  hydram- 
nios,  by  multiple  pregnancies,  and,  above  all,  by  the  contracted  pelvis. 
On  account  of  the  more  frequent  concurrence  of  these  conditions  in 
multiparae,  the  accident  is  oftener  found  in  them  than  in  primiparae. 

The  diagnosis  of  prolapsed  funis  is  easy.  If  necessary,  the  loop  can 
be  drawn  outside  of  the  vagina.  Previous  to  rupture  it  forms  a  smooth, 
round,  compressible,  mobile  body,  not  to  be  confounded  with  any  other 
floating  object  liable  to  be  encountered  within  the  ovum.  When  the 
pulsations  of  the  umbilical  vessels  are  distinctly  felt,  the  child  is  de- 
monstrated to  be  alive.  In  the  second  stage,  however,  the  pulsations 
may  cease  for  a  moment  during  a  pain,  to  return  again  in  the  ensu- 
ing interval.  As  the  heart  sometimes  continues  to  beat  for  a  few 
minutes  after  the  circulation  in  the  cord  has  ended,  it  is  proper  to 
carefully  auscultate  before  assuming  death  to  have  taken  place  (Spie- 
gelberg). 

The  prognosis,  so  far  as  regards  the  children,  is  extremely  unfavor- 
able, more  than  one  half  dying  during  labor.  This  fatality  is  owing 
to  the  pressure  to  which  the  cord  is  subjected  during  the  passage  of 
the  child  through  the  pelvis.  There  are,  however,  a  variety  of  cir- 
cumstances which  substantially  modify  the  extent  of  the  danger. 
Thus,  in  transverse  presentations  the  cord  is  scarcely  or  not  at  all 
exposed  to  pressure.  In  breech  presentations  the  prognosis  is  good, 
owing  to  the  soft  consistence  and  small  size  of  the  pelvic  extremity, 
and  to  the  fact  that,  where  the  life  of  the  child  is  in  peril,  the  condi- 
tions are  such  as  to  permit  of  speedy  extraction. 

The  most  serious  cases  are  those  where  prolajose  occurs  as  a  compli- 
cation of  head  presentations.  Engelmann  found  that  the  infant  mor- 
tality in  the  latter  was  sixty-four  per  cent.,  while  in  footling  presenta- 

*  These  statistics  I  have  borrowed  from  an  article  on  the  "  Presentation  of  the  Funis," 
by  Dr.  J.  G.  Meachem,  reprinted  from  "  The  Transactions  of  the  State  Medical  Society  of 
Wisconsin,"  1880. 


584 


THE  PATHOLOGY  OF  LABOR. 


tions  it  was  but  thirty-two  per  cent.  Favorable  conditions  in  head 
presentations  are  a  large,  roomy  pelvis  and  preservation  of  the  mem- 
branes until  cervical  dilatation  is  completed.  Of  unfavorable  import 
are  a  deep  placental  site,  a  contracted  pelvis,  and  early  rupture  of  the 
membranes. 

Treatment. — From  the  foregoing  it  will  be  seen  that  the  one  indi- 
cation for  treatment  in  this  anomaly  is  to  relieve  the  cord  from  press- 
ure. The  conduct  of  the  physician  in  each  individual  case  will 
depend  upon  the  presentation  and  the  modifying  circumstances. 

If  the  head  presents,  so  long  as  the  membranes  remain  intact,  and 
the  dilatation  of  the  cervix  is  incomplete,  an  expectant  attitude  should 
be  maintained.  Premature  rupture  should  be  guarded  against  by 
placing  the  patient  in  the  latero-prone  position,  by  forbidding  her  to 
strain,  and  by  supporting  the  membranes  by  means  of  a  moderately 
distended  Barnes  dilator  introduced  into  the  vagina.  It  is  not  rare 
in  this  class  of  cases,  as  the  head  descends,  for  the  cord  to  be  with- 
drawn upward  into  a  place  of  safety.  The  more  complete  the  dilata- 
tion before  rupture,  the  more  rapid  the  subsequent  delivery  of  the 
child,  and  the  greater  the  chance,  therefore,  of  preserving  its  life.  If, 
however,  upon  auscultation,  there  are  signs  of  failing  heart-action,  an 
attempt  should  be  made  to  push  the  cord  upward  with  the  fingers 
through  the  membranes.  In  case  of  success,  in  order  to  j)revent  a 
relapse,  the  sac  should  be  ruptured,  and  the  head  should  be  brought 
down  so  as  to  fill  the  cervical  canal. 

After  rupture  of  the  membranes,  if  the  cervix  is  well  dilated,  the 
pains  are  good,  and  the  head  enters  quickly  into  the  pelvic  cavity,  the 
case  may  be  left  to  nature.  Spiegelberg  mentions  five  cases,  in  his 
own  practice,  where  the  birth  of  the  child  took  place  so  rapidly  that 
no  harm  resulted  from  the  descent  of  the  cord.  If  the  pains  are 
feeble,  and  speedy  progress  is  not  made,  the  forceps  should  be  a^oplied. 

If,  after  dilatation  of  the  cervix,  the  head  remains  high  and  mov- 
able above  the  brim,  the  forceps  should  not  be  employed.  It  is  then 
dangerous  to  the  mother,  and  offers  but  scant  hope  of  proving  of  ser- 
vice to  the  child.  The  choice  in  such  cases  falls  either  uj^on  repo- 
sition of  the  cord,  or  version. 

Reposition  of  the  prolapsed  cord,  as  the  milder  procedure,  should 
be  first  attempted.  The  reposition  is  most  easily  accomplished  in  the 
knee-chest  position,  as  has  been  beautifully  demonstrated  by  Gail- 
lard  Thomas.*  By  the  simple  plan  of  reversing  the  direction  of  the 
uterine  axis,  all  the  conditions  which  had  previously  favored  the 
descent  of  the  cord  are  made  to  promote  its  return  into  the  uterine  cav- 
ity. Thus  the  intra-abdominal  pressure  is  removed,  the  amniotic  fluid 
is  retained,  the  head  is  easily  pushed  to  one  side  so  as  to  permit  the 

*  Thomas,  "  Postural  Treatment  of  Prolapsed  Funis,"  "  Trans,  of  the  New  York 
Acad,  of  Med.,"  1858. 


PROLAPSE  OF  THE  FUNIS,  ETC. 


585 


introduction  of  the  hand,  and  the  cord  tends  to  glide  by  its  own 
weight  over  the  declivity  furnished  by  the  anterior  wall  to  the  fundus. 
The  loop  should  be  seized  in  the  hollow  of  the  hand,  and  should  be 
carefully  sheltered  from  pressure.  It  should  be  shoved  beyond  the 
greatest  circumference  of  the  head,  and,  where  possible,  to  the  back  of 
the  child's  neck.  As  in  all  cases  where  the  hand  has  to  be  passed 
through  the  cervix,  the  uterus  should  be  sustained  by  pressure  from 
without.  With  the  advent  of  a  pain  all  manipulations  should  cease, 
to  be  renewed,  however,  as  relaxation  follows.  If  the  replacement 
proves  successful,  the  hand  should  be  withdrawn  gradually,  while  the 
head  becomes  fixed  in  the  lower  segment.  This  latter  result  may  fre- 
quently be  expedited  by  judiciously  directed  external  pressure.  As  a 
precaution  against  relapse,  the  patient  should  be  placed  in  the  latero- 
prone  position,  with  the  hips  elevated  by  a  pillow. 

The  Postural  Treatment  of  Prolapse  of  the  Funis. — K.  F.  J.  Birnbaum*  finds 
that  quite  frequent  mention  has  been  made  by  authors  of  the  advantages  to  be 
derived  from  posture  in  the  treatment  of  cases  of  prolapsed  funis.  The  works  of 
Camper,  published  about  the  middle  of  the  seventeenth  century,  and  referred 
to  by  Kiestra,  he  had  no  means  of  obtaining  access  to.  Deventer  t  considers  the 
subject  of  prolapsed  funis  in  extenso.,  takes  up  its  different  modifications,  its  efi'ect 
upon  parturition  and  the  life  of  the  child,  and  the  treatment  it  demands.  In  cases 
where  the  cord  was  pressed  against  either  ilium,  he  directed  to  place  the  woman 
upon  the  corresponding  side,  with  raised  pelvis,  and  with  the  hand  (right  hand  if 
on  the  left  side,  and  vice  versa)  to  lift  the  head,  replace  the  cord,  then,  as  seemed 
advisable,  either  to  bring  the  head  into  the  pelvis,  or  to  turn  and  extract  by  the 
feet.  When  the  cord  was  pressed  against  the  pubes  or  the  sacrum,  he  advised 
that  the  midwife  should  place  the  woman  upon  her  knees  with  her  body  thrown 
forward,  and  that,  in  this  position,  the  accoucheur  should  raise  the  head  and 
return  the  cord ;  if  the  woman  should  be  too  weak  for  this,  she  should  be  placed 
upon  the  side  with  one  limb  drawn  up  under  the  body.  John  Mowbray  X  ad- 
vises that  the  woman,  if  strong  enough,  should  be  placed  upon  her  knees  and 
elbows  in  cases  where  the  cord  lies  next  the  sacrum  or  the  pubes.  Henry 
Bracken,  a  pupil  of  Boerhaave,*  proposed  returning  the  funis  in  head  presenta- 
tions, with  the  woman  placed  upon  the  knees,  and  afterward  to  bring  the  fetal 
head  into  the  pelvis.  Ludwig  Wilhelm  von  Knoer  ||  devoted  a  long  chapter  to 
funis  presentations.  He  says  :  "  Introduce  the  hand  so  soon  as  the  membranes 
rupture,  and,  according  to  the  position  of  the  child,  perform  either  podalic  or 
cephalic  version,  placing  the  woman  at  the  same  time  upon  her  knees  to  prevent 
the  protrusion  of  the  cord."  George  Daniel  Boessel  ^  recommends  turning  in 
cases  of  funis  presentation,  and,  in  cases  of  difficulty  to  perform  version,  with 

*  "Monatsschr.  f.  Gcburtsk.,"  October,  1867. 

■j-  "  Operationes  chirurgicae  novum  lumen  exhibentes  obstetricantibus,"  Lugd.  Bat., 

noi. 

X  "  The  Female  Physician,  containing  all  the  Diseases  incident  to  that  Sex,"  Lon- 
don, 1724. 

*  "  Midwife's  Companion ;  or  a  Treatise  of  Midwifery,"  London,  1737. 
II  "  Frauen  Zimmer  Medicus,"  Leipsic,  1747. 

^  "Grundlegung  zur  Hebammen  Kunst,"  Flensburg  and  Leipsic,  1756. 


586 


THE  PATHOLOGY  OF  LABOR. 


tlie  woman  placed  upon  the  knees.  In  recent  times,  Van  Eitgen  has  certainly 
been  the  most  ardent  partisan  of  postural  methods  of  treatment.  In  his  work 
entitled  "  Anzeigen  der  mechanischen  Hiilfen  bei  Entbindungen,"  published  in 
1820,  he  recommends  them  in  a  great  variety  of  circumstances,  but  not  then  for 
prolapsed  funis;  but  in  his  "Lehr-  und  Handbuch  der  Geburtshtilfe  fur  Hebam- 
men"  (Mainz,  1838)  he  says:  "When  the  funis  presents,  the  midwife  should 
instantly  send  for  the  accoucheur;  meanwhile  she  should  herself  place  the 
woman,  if  strong  enough,  upon  her  knees  and  elbows,  and  attempt  the  replace- 
ment of  the  cord;  if  the  woman  is  too  weak  to  admit  of  this,  she  should  be 
placed  upon  her  side,  with  elevated  pelvis.  That  side  should  be  chosen  upon 
which  the  funis  is  not  situated.  If  tlie  manipulation  is  successful,  the  posture 
should  be  maintained  to  prevent  a  recurrence  of  the  prolapse."  He  recommends 
the  position  upon  the  elbows  and  knees  for  cases  of  prolapsed  funis  and  trans- 
verse presentations  in  breech  or  foot  presentations,  also  where  the  head  is  mov- 
able above  the  brim,  and  where  there  is  no  attainable  presenting  part.  He  ad- 
vises returning  the  funis  high  up  with  the  hand,  and  then  to  let  it  fall  into  the 
uterus,  where  it  would  no  longer  be  subjected  to  pressure.  After  reposition 
place  the  woman  upon  her  side,  with  raised  pelvis.  Sometimes  the  postural 
method  suffices  without  any  manipulations.  Kiestra*  advises  the  position  upon 
the  knees  and  elbows  in  cases  where  the  cord  is  felt  near  the  head  previous 
to  rupture  of  the  membranes,  to  prevent  the  occurrence  of  prolapse.  After  the 
rupture  of  the  membranes,  he  says,  the  same  position  should  be  employed  to 
facilitate  the  return  of  the  cord,  and  should  be  maintained  until  the  head  is  fairly 
engaged  in  the  pelvis.  Where  the  position  could  not  be  endured  long  enough, 
he  counseled  placing  the  woman  in  a  half-kneeling,  half-recumbent  posture,  with 
the  side  supported  by  cushions.  Theobold,  in  1860,  hit  upon  the  same  idea.  He 
considered  the  most  favorable  condition  for  the  return  of  the  funis  was  to  place 
the  woman  upon  her  head,  but,  in  view  of  the  difficulty  attending  the  execution 
of  this  manoeuvre,  compromised  the  matter  by  suggesting  the  position  upon  the 
elbows  and  knees. 

The  advantages  of  the  postural  method  in  the  treatment  of  pro- 
lapsed cord  are  beyond  all  question.  It  is,  however,  difficult  to  per- 
suade the  woman  to  long  maintain  so  constrained  an  attitude,  and  the 
cases  are  not  rare  where,  in  spite  of  gravity,  the  cord  refuses  to  remain 
within  the  uterine  cavity.  Efforts  at  replacement  should  not,  there- 
fore, be  long  continued.  It  is  impossible  to  handle  the  cord  for  any 
lengthy  period  without  enfeebling  the  force  of  the  fetal  heart.  So 
soon,  therefore,  as  it  becomes  evident  that  nothing  is  to  be  gained  by 
further  persistence,  the  hand  should  be  pushed  up  to  the  feet,  and  the 
safety  of  the  child  should  be  secured  by  speedy  extraction.  In  cases 
of  contracted  pelvis  the  question  of  version  must  be  decided  with  ref- 
erence to  the  interests  of  the  mother,  as  a  difficult  breech  delivery 
complicated  by  prolapsed  funis  offers  but  a  sorry  prospect  of  saving 
the  life  of  the  child. 

If  the  membranes  rupture  and  the  cord  is  prolapsed  while  the  cer- 
vix is  still  narrow  and  rigid,  an  attempt  should  first  be  made  to'j)ush 

*  "Nederl.  Weckbl.,"  April,  1855. 


PROLAPSE  OF  THE  FUNIS,  ETC. 


587 


back  the  cord  with  two  fingers  after  placing  the  woman  in  the  genu- 
pectoral  position.  As  a  rule,  however,  instrumental  replacement  will 
be  necessary.  I  have  been  in  the  habit  of  employing  for  the  purpose, 
as  recommended  by  Dudan,  a  large  English  catheter,  which  possesses 
the  advantage  of  forming  one  of  the  ordinary  proj)erties  of  the  phy- 
sician. The  method  of  using  the  instrument  is  as  follows  :  A  piece 
of  tape  should  first  be  fastened  loosely  around  the  cord,  the  stylet 
should  then  be  made  to  emerge  at  the  eye  of  the  catheter,  and  a  loop 
of  the  tape  should  be  placed  in  the  angle  it  forms.  By  returning  the 
stylet  and  pushing  it  forward  to  the  extremity  of  the  tube,  the  band  is 
held  firmly.  After  replacing  the  prolapsed  cord,  the  catheter  is  read- 
ily detached  by  the  withdrawal  of  the  stylet.  Braun  von  Fernwald, 
who  is  the  author  of  the  best  of  the  repositors  made  expressly  for  the 
prolapsed  cord,  says  that  the  catheter  is  almost  the  only  instrument 
to  which  he  now  resorts. 

Instrumental  replacement  is  apt  to  prove  a  veritable  labor  of  Sisy- 
phus. As  one  loop  is  pushed  np  another  comes  down,  or  the  entire 
mass  is  returned  with  infinite  trouble  to  the  uterus  only  at  once  to  be 
projected  into  the  vagina.  Rober- 
ton  has  proposed  a  handy  plan  for 
such  cases,  which  certainly  merits 
a  trial.  It  consists  in  first  passing 
a  piece  of  twine  doubled  through 
an  elastic  catheter,  so  that  the  loop 
makes  its  appearance  at  the  eye. 
Through  this  loop,  a  loo23  of  the 
cord  should  be  drawn.  The  ends 
of  the  twine  should  then  be  knotted 
to  prevent  them  from  slipping  ;  the 
catheter  should  be  armed  with  a 
stylet,  and  should  be  pushed  up- 
ward into  the  uterus,  carrying  the 

cord  with   it.     After   introducing  Fig.  225.-Robertson's  repositor. 

the  catheter,  the  stylet  should  be 

withdrawn,  and  the  instrument  should  be  left  behind  to  keep  the  cord 
from  again  prolapsing. 

In  one  case  Dr.  Ashford  *  succeeded  in  attaching  the  cord  to  a 
Gariel  pessary.  The  latter  was  then  carried  into  the  uterus,  and  in- 
flated to  prevent  its  expulsion. 

If  neither  the  cord  can  be  returned  nor  the  child  extracted,  it  is 
proper  to  try  by  Braxton  Hicks's  method  to  convert  the  head  presenta- 
tion into  one  of  the  shoulder  or,  better  still,  of  the  breech,  in  order  by 
so  doing  to  relieve  the  umbilical  vessels  from  pressure.    Of  course,  if 

*  F.  A.  Ashford,  "'Ballooning'  the  Prolapsed  Umbilical  Cord,"  "Am,  Jour,  of  Ob- 
stet.,"  October,  1878,  p.  745. 


588 


THE  PATHOLOGY  OF  LABOR. 


the  prolapsed  funis  is  associated  with  pelvic  contraction,  the  rule 
heretofore  given  to  consult  first  the  safety  of  the  mother  remains  the 
guiding  one  in  jDractice. 

In  face  presentations  version  is  indicated,  as,  owing  to  the  imper- 
fect manner  in  which  the  face  closes  the  uterine  orifice,  replacement 
of  the  cord  is  not  likely  to  prove  successful.  If  the  opening  through 
which  the  cord  makes  its  way  into  the  vagina  is  produced  by  a  pro- 
lapsed extremity,  the  latter,  of  course,  should  be  pushed  back  after  the 
cord  has  been  returned.  In  footling  cases  the  pressure  on  the  cord 
does  not  begin  until  long  after  the  extremities  can  be  reached  and 
utilized  for  extraction.  In  full  breech  cases,  where  the  size  of  the 
presenting  part  might  interfere  with  the  funic  circulation,  where  it  is 
possible  to  return  the  cord  with  the  hand  it  is  equally  practicable  to 
bring  down  an  extremity.  In  cross-births,  before  the  shoulder  becomes 
wedged  in  the  pelvis  the  cord  is  in  no  danger.  No  treatment  is  there- 
fore necessary,  except  that  indicated  by  the  faulty  presentation. 

SUSPEJ^DED   AkIMATIOK,  OK  ASPHYXIA  NEONATORUM. 

Definition. — The  term  suspended  animation  is  applied  to  such 
grades  of  congenital  asphyxia  in  the  living  new-born  child  as  are  not 
incompatible  with  the  continuance  of  its  life.*  A  larger  number  of 
males  than  of  females  are  born  asphyxiated,  and  the  children  of  primi- 
parae  are  more  liable  to  this  condition  than  those  of  multiparae.  f 

Etiology. — A  perfect  comprehension  of  the  etiology  of  suspended 
animation  must  be  based  upon  thorough  knowledge  of  the  physiology 
of  intra-uterine  life  and  of  the  conditions  necessary  to  its  preservation. 
The  foetus  lives  only  by  virtue  of  its  connection  with  the  placenta,  in 
which  all  the  nutritive  elements  necessary  to  its  life  are  transmitted 
to  its  circulation  from  the  maternal  blood,  which  in  turn  receives  and 
removes  the  products  of  retrograde  metamorphosis  occurring  in  the 
fetal  tissues.  The  placenta  performs  for  the  foetus  the  functions 
assumed  after  birth  by  the  digestive  and  respiratory  organs. ;[  The 
proper  performance  of  these  functions  is  indispensable  to  the  life  of 
the  foetus,  which  is  forfeited  so  soon  as  they  are  completely  inter- 
rupted or  imperiled  by  their  partial  abrogation — unless,  indeed,  the 
speedy  accomplishment  of  delivery  afford  the  extra-uterine  resjoiratory 
and  digestive  functions  an  opportunity  of  compensating  for  the  corre- 
sponding intra-uterine  ones.  Since  the  alinrentary  fluids  contained  in 
the  blood-plasma  can  be  longer  dispensed  with,  without  prejudicial 
results,  than  the  oxygen,  the  cause  of  fetal  death  or  of  suspended  ani- 

*  SciiuLTZE,  "Dcr  Scheintod  Neugeborenen,"  Jena,  1871,  pp.  9,  101. 

f  PoppKL,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxv,  1865,  Supplement.  Heft,  p.  57. 

X  ZwEiFEL,  "Die  Resp.  des  Foetus,"  "Arch.  f.  Gynaek.,"  Bd.  ix,  1876,  p.  304;  Feh- 
LING,  "Arch.  f.  Gynaek.,"  Bd.  ix,  1876,  p.  318;  Boehr,  " Monatsschr.  f.  Geburtsk.," 
Bd.  xxii,  1863,  p.  408. 


PROLAPSE  OF  THE  FUNIS,  ETC. 


589 


mation  is  chiefly  asphyxia  from  deficient  oxygenation.*  The  causes 
of  the  interruption  in  the  dilfusion  of  gases  and  of  the  consequent 
fetal  asphyxia  are  of  two  varieties  :  1.  Those  which  interfere  with  pla- 
cental respiration  by  limiting  or  checking  the  maternal  supply  of  oxy- 
gen, as  in  cases  of  death,  of  grave  anaemia,  of  ante-partum  haemor- 
rhage, or  of  pulmonary  diseases  on  the  part  of  the  mother,  whereby 
the  amount  of  oxygen  in  her  blood  is  diminished.  2.  Those  which 
interfere  with  or  entirely  prevent  the  absorption  of  oxygen  by  the  fetal 
blood.  Among  the  latter  causes  may  be  mentioned  torsion  and  com- 
pression of  the  umbilical  cord,  partial  or  complete  separation  of  the 
placenta,  diminution  of  the  fetal  cardiac  action  by  cerebral  or  thoracic 
compression,  and  arrest  of  the  placental  circulation.!  In  cases  of  nor- 
mal delivery  the  extra-uterine  respiratory  function  assumes  control 
so  soon  as  the  uterine  contractions  have  sufficiently  compressed  the 
placenta  to  prevent  proper  oxygenation  of  the  fetal  blood.  The  in- 
adequately oxygenated  products  of  disassimilation  are  here  supposed 
to  act  as  powerful  stimulants  to  the  medullary  respiratory  center,  and 
to  produce  contractions  of  the  respiratory  muscles.  J  So  long  as  the 
diffusion  of  gases  is  normally  provided  for  by  the  placenta,  no  stimu- 
lus is  conveyed  to  the.  medulla.  When,  however,  this  source  of  aera- 
tion for  the  fetal  blood  is  removed,  spontaneous  respiration  must  at 
once  begin.  Most  authorities  are  of  the  oj)inion  that  this  is  the  pre- 
ponderating cause  of  the  first  extra-uterine  respiratory  movements.* 
Chilling  of  the  fetal  skin  by  the  atmosphere  is  held  by  Kristeller,  || 
and  regurgitation  of  the  placental  blood  toward  the  fetal  heart  by 
Lahs,"^  to  be  other  causes  of  the  first  spontaneous  respirations.  Re- 
spiratory movements  are  produced  in  the  manner  described,  whether 
the  interruption  of  fetal  haematosis  occur  after  or  before  the  expul- 
sion of  the  placenta  from  the  uterine  cavity,  provided  the  respir- 
atory center  and  the  muscles  of  respiration  be  sufficiently  developed 
to  respectively  originate  and  react  to  nervous  impulses.  In  each  in- 
stance the  thorax  is  dilated,  the  pulmonary  capillaries  are  filled  with 
blood  by  the  right  ventricle,  and  whatever  surrounds  the  external  air- 
passages  is  aspirated,  if  these  be  permeable,  into  the  trachea  and  bron- 
chi. In  the  former  case  the  surrounding  medium  is  air,  the  fetal 
blood  is  duly  aerated  and  the  extra-uterine  respiratory  function  secure- 
ly established.  When  respiration  begins  in  the  uterine  cavity,  how- 
ever, only  a  little  air  and  that  in  exceptional  instances  ^  is  inspired, 
while  mucus,  blood,  liquor  amnii,  vernix  caseosa,  and  meconium  are 

*  ScHROEDER,  "  Lehrbuch,"  p.  714.  f  Spiegelberg,  "  Lehrbuch,"  p.  663. 
\  Schroeder,  op.  cit. 

*  Schwartz,  "Arch.  f.  Gynaek.,"  Bd.  i,  1870,  p.  362;  Boehr,  "  Monatsschr.  f.  Ge, 
burtsk.,"  Bd.  xxv,  1865,  p.  336  ;  Schultzk,  op,  cit,  p.  105. 

I  Kristeller,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxv,  1865,  p.  327. 

^  Lahs,  "  Arch.  f.  Gynaek.,"  Bd.  iv,  1872,  p.  312. 

^  Bartscher,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  ix,  1857,  p.  294. 


590 


THE  PATHOLOGY  OF  LABOR. 


aspirated  in  considerable  quantities.  Aeration  of  the  fetal  blood  can 
not  now  be  accomplished  by  either  method  of  respiration.  The  poison- 
ous products  of  tissue  disintegration  accumulate.  The  irritability  of 
the  medullary  centers  diminishes.  Eespiratory  movements  become 
infrequent,  and  are  finally  arrested.  The  heart  becomes  paralyzed, 
and  the  foetus  dies  unless  delivery  be  speedily  accomplished.  If,  now, 
the  child  be  extracted  asphyxiated,  but  not  dead,  its  condition  is  said 
to  be  that  of  suspended  animation. 

Provided  the  interference  with  placental  respiration  be  of  a  tempo- 
rary character,  the  disturbances  of  the  fetal  functions  due  to  intra- 
uterine respiration  may,  according  to  Schultze,*  be  compensated  for 
in  the  following  manner  :  Inspirations  occur,  at  first,  as  above  de- 
scribed, from  interruption  of  the  placental  circulation.  Since,  how- 
ever, the  medullary  respiratory  center  no  longer  receives  an  adequate 
supply  of  arterial  blood,  its  irritability  diminishes  and  respiratory 
movements  cease.  The  aspiration  of  blood  from  the  right  ventricle 
into  the  pulmonary  circulation  is  now  arrested,  and  the  placental  ves- 
sels are  refilled.  Owing  to  paralysis  of  the  pneumogastric  nerves,  from 
over-stimulation,  the  cardiac  activity  is  restored,  and,  if  the  obstruc- 
tion to  the  placental  circulation  be  transitory,  the  placenta  will  reas- 
sume  its  respirator}^  function.  This  hypothesis  exj^lains  the  fact  that 
foetuses,  which  are  known  from  observation  to  have  breathed  in  utero, 
are  sometimes  not  born  in  a  state  of  asphyxia.  Suspended  anima- 
tion may  occur  without  antecedent  intra-uterine  respiration.  This  is 
the  case  when  disturbance  or  arrest  of  the  placental  functions  takes 
place  in  foetuses  so  immature  that  their  medullary  centers  can  not 
respond  to  the  irritation  of  insufficiently  oxygenated  disassimilative 
products  by  originating  the  nervous  impulse  necessary  for  the.  produc- 
tion of  respiratory  movements. 

Another  cause  of  suspended  animation  unattended  by  intra-uterine 
respiration  is  a  very  slow  progress  of  the  placental  respiratory  dis- 
turbance, and  a  consequent  gradual  diminution  of  the  amount  of  oxy- 
gen in  the  fetal  blood.  The  deficiency  in  oxygen  is,  at  first,  so  slight 
as  not  to  stimulate  the  medullary  center,  and  when  the  deficiency  be- 
comes more  marked  the  irritability  of  the  medulla  has  been  so  much 
depressed  that  it  is  no  longer  capable  of  originating  a  respiratory  im- 
pulse. In  this  case  the  foetus  dies  or  passes  into  a  condition  of  sus- 
pended animation  without  having  breathed  at  all.*  Compression  of 
the  fetal  brain  due  to  a  contracted  pelvis,  to  intra-cranial  haemorrhage, 
to  the  use  of  the  forceps, f  or  to  delivery  in  breech  positions,  may  occa- 
sion death  or  suspended  animation  without  exciting  respiratory  move- 
ments. The  rationale  of  such  cases  is  as  follows  :  Cerebral  compres- 
sion reduces  or  even  arrests  the  heart's  action  by  irritating  the  pneu- 

*  Schultze,  op.  cit,  pp.  102  et  scq. 

f  DonuN,  "Arch.  f.  Gynaek.,"  Bd.  vi,  1874,  p.  365. 


PROLAPSE  OF  THE  FUNIS,  ETC. 


591 


mogastric  nerye.  The  placental  respiratory  function  is  thus  impaired, 
the  fetal  blood  is  consequently  deprived  of  oxygen,  and  the  irritability 
of  the  medulla  so  reduced  that  the  latter  can  no  longer  originate  re- 
spiratory movements.  *  If  intra-cranial  extravasations  are  located  upon 
the  convexity  of  the  cerebrum  they  are  comparatively  innocuous,  since 
the  medulla  is  not  compressed.  Their  most  pernicious  effect  is  natu- 
rally observed  when  they  are  situated  at  the  base  of  the  brain.  It  is 
doubtful,  according  to  Schwartz,  f  whether  intra-uterine  respiration, 
without  asphyxia,  may  ever  result  from  cerebral  compression,  as  is 
maintained  by  Poppel.  I 

Morbid  Anatomy. — Schultze  recognizes  two  stages  of  suspended 
animation,  which  correspond  to  the  terms  asphyxia  livida  and  pallida, 
usually  employed  to  designate  these  respective  conditions.*  The 
boundary-line  between  the  two  stages  is  marked  by  the  loss,  on  the 
part  of  the  muscles,  of  their  tonic  contractility.  In  the  tirst  stage  the 
muscular  tone  is  still  preserved.  Although  there  are  no  spontaneous 
muscular  contractions,  the  extremities  are  not  completely  relaxed,  nor 
does  the  head  drop.  Reflex  movements  are  easily  produced  by  surface 
irritation.  The  skin  is  dusky-red  or  cyanotic,  the  cutaneous  vessels  are 
turgid,  the  conjunctivae  injected,  and  the  eyeballs  protruding.  The 
cardiac  and  umbilical  pulsations  are  slow  but  forcible.  The  umbilical 
vessels  are  fully  distended.  Respiratory  movements  usually  occur  only 
after  a  certain  interval.  They  are  at  first  feeble,  superficial,  and  at- 
tended by  facial  contortions,  but  soon  become  more  powerful.  The 
increased  deficiency  in  oxygen,  occasioned  by  delivery,  often  furnishes 
to  the  medulla,  in  this  stage  of  suspended  animation,  a  stimulus  of 
sufficient  intensity  to  cause  spontaneous  respiratory  movements.  The 
same  result  is  attained  by  irritation  of  the  surface.  If  respiration  does 
not  ensue,  from  either  cause,  the  child  passes  into  the  second  stage  of 
asphyxia. 

In  the  second  stage  of  suspended  animation,  or  asphyxia  pallida, 
the  children  are  exceedingly  anaemic.  The  conjunctivae  are  without 
luster  ;  the  surface  is  cold  ;  the  sphincters  are  relaxed ;  the  limbs, 
head,  and  lower  jaw  hang  loosely  down.  Reflex  movements  do  not 
occur.  The  cardiac  beats  are  frequent  and  feeble.  The  umbilical 
pulse  is  almost  or  quite  imperceptible.  The  umbilical  vessels  are 
empty.  Either  no  spontaneous  respiratory  movements  occur,  or  they 
are  few,  snapping,  and  produced  by  the  diaphragm  without  the  par- 
ticipation of  the  facial,  nasal,  or  maxillary  muscles.  The  respirations 
are  ineffectual,  since  ^post-mortem  examination  reveals  little  or  no  air 
in  the  bronchi,  which  are  usually  filled  with  fluid  matter,  and  since 

*  Frankenhauser,  "Monatsschr.  f.  Gcburtsk.,"  Bd.  xv,  1860,  p.  368. 
f  Schwartz,  "  Arch.  f.  Gynack.,"  Bd.  i,  18V0,  pp.  365,  377. 

\  Poppel,  op.  ciL,  p.  57. 

*  Schultze,  op.  cU.,  pp.  6,  130,  147. 


592  THE  PATHOLOGY  OF  LABOR. 

no  rales  are  heard  during  the  respiratory  efforts.  The  medulla  is  so 
completely  paralyzed  that  the  stimulus  of  the  increased  deficiency  in 
oxygen,  attendant  upon  delivery,  merely  produces  these  futile  respira- 
tory efforts.  Should  artificial  means  succeed  in  restoring  the  child, 
the  first  signs  of  its  resuscitation  will  be  refilling  of  the  cutaneous 
capillaries  and  returning  muscular  tonicity.  The  morbid  anatomical 
features  of  suspended  animation  vary  according  as  that  condition  has 
or  has  not  been  attended  by  intra-uterine  respiration.  In  the  latter 
case  the  blood  is  dark  and  uncoagulated.  The  pulmonary  vessels  are 
widely  distended.  The  lungs  are  enlarged,  heavy,  and  of  a  dark-red 
color.  Numerous  pulmonary,  subpleural,  subpericardial,  and  suben- 
docardial ecchymoses  are  present.  The  pulmonary  extravasations  are 
more  extensive  than  in  cases  of  asphyxia  accompanied  by  intra-uterine 
respiration,  for  the  reason  that,  in  the  latter,  the  aspirated  fluids  offer 
a  certain  support  to  the  distended  capillaries.  Pulmonary  congestion 
and  ecchymosis  may  be  absent  if  the  inspirations  were  ineffectual,  in- 
frequent, and  of  short  duration.  The  obstruction  of  the  pulmonary 
circulation  further  produces  venous  congestion  of  the  surface,  of  the 
abdominal  organs,  and  of  the  encephalon,  resulting  in  subconjunctival, 
meningeal,  and  cerebral  haemorrhages.  Ecchymoses  may,  also,  be 
found  beneath  and  upon  the  pericranium.  Aside  from  the  extrava- 
sated  blood,  no  foreign  matters  are  found  in  the  bronchi.  The  absolute 
proof  that  the  asphyxia  of  still-born  children,  or  of  those  born  in  a 
moribund  condition,  was  attended  by  intra-uterine  respiration  consists 
in  the  discovery,  within  the  bronchi,  of  substances  introduced  by  tho- 
racic aspiration.  When  the  proof  is  lacking,  inspiration  may  still 
have  occurred,  but  the  entrance  of  foreign  bodies  has  been  prevented 
through  occlusion  of  the  nose  and  mouth  by  portions  of  the  membranes, 
or  by  close  apposition  to  them  of  the  maternal  soft  parts.  The  quan- 
tity of  aspirated  material  will  depend  upon  its  character  and  the  force 
of  the  inspirations.  The  tough  cervical  mucus  penetrates  only  to  the 
trachea  and  primary  bronchi.  The  liquor  amnii,  containing  meconium, 
vernix  caseosa,  and  blood  and  downy  hairs,  may  even  reach  the  terminal 
bronchioles.  If  air  had  found  an  entrance  into  the  uterine  cavity,  it 
is  also  present  in  the  bronchi,  and,  exceptionally,  in  the  stomach  and 
duodenum.  The  dilatation  of  the  Eustachian  tubes,  as  a  consequence 
of  the  first  inspirations,  permits,  in  some  instances,  according  to 
Wendt,*  the  penetration  of  liquor  amnii  into  the  middle  ear.  The 
pulmonary  ecchymoses  are  less  numerous  and  extensive  in  asphyxia 
attended  by  intra-uterine  respiration  than  in  the  other  variety,  for  rea- 
sons above  stated,  but  congestion  and  extravasations  in  the  abdominal 
and  cerebral  organs  are  quite  as  constant  and  important. 

Diagnosis. — An  important  diagnostic  symptom  of  beginning  as- 
phyxia is  diminished  frequency  of  the  fetal  heart-beats,  due  to  inhibi- 
*  Spiegelberg,  "  Lehrbuch,"  p.  667. 


PROLAPSE  OF  THE  FUNIS,  ETC. 


593 


tion  of  the  placental  respiration.  This  has  no  significance  if  it  be 
manifest  only  during  the  pains,  since  it  is  then  a  physiological  occur- 
rence due  to  the  mechanical  compression  of  the  foetus  or  to  exj)ression 
of  the  placental  blood  into  the  fetal  vessels.  If  it  persist,  however, 
during  the  interval  between  the  pains,  and  be  progressive,  it  is  of  seri- 
ous import,  betokening  either  considerable  compression,  or  irritation  of 
the  medulla  by  an  excess  of  deoxygenated  blood.  The  diminished 
frequency  is  sometimes  succeeded  by  increased  rapidity  of  the  cardiac 
contractions,  indicating  paralysis  of  the  pneumogastric,  and,  conse- 
quently, a  more  advanced  stage  of  suspended  animation.*  This  in- 
creased rapidity  is,  probably,  invariably  preceded  by  the  diminished 
frequency  of  the  heart's  action  already  alluded  to.  The  evacuation  of 
meconium  is  also  diagnostic  of  asphyxia,  provided  it  be  not  merely  the 
result  of  the  mechanical  compression  exerted  upon  the  child  in  breech 
presentations.  The  appearance  of  the  meconium  is,  probably,  due  to 
the  increased  intestinal  peristalsis  attendant  upon  asphyxia,  although, 
perhaps,  in  part  occasioned  by  relaxation  of  the  sphincters  and  com- 
pression of  the  abdomen  by  the  contracting  diaphragm.  The  dis- 
charge of  meconium,  accordingly,  usually  attends  that  form  of  sus- 
pended animation  in  which  intra-uterine  respiration  has  occurred,  and 
is  absent  in  those  cases  of  gradually  induced  asphyxia  unaccompanied 
by  respiratory  efforts.  The  differential  diagnosis  between  these  two 
varieties  is  completed,  after  delivery,  by  the  detection  of  bronchial 
rales,  due  to  the  aspiration  of  intra-uterine  fluids,  in  all  cases  of  intra- 
uterine respiration  except  those  in  which  the  external  air-passages  were 
occluded.  The  discharge  of  meconium  is  sometimes  not  indicative  of 
any  pathological  condition.  Schultze  f  detected  intra-uterine  respira- 
tion by  abdominal  auscultation,  as  well  as  by  intra-uterine  palpation, 
and  numerous  observers  have  heard  the  vagitus  uterinus,  or  intra- 
uterine cry,  which  bears  testimony  to  the  entrance  of  air  into  the 
uterus,  and  to  the  occurrence  of  respiratory  movements.];  When  de- 
livery has  been  partially  accomplished,  the  diagnosis  of  asphyxia  is 
easily  made  from  the  failing  fetal  pulse,  the  cyanosis,  the  forcible 
respiratory  efforts,  and  the  relaxation  of  the  child's  muscles. 

Prognosis. — The  prognosis  depends  largely  upon  the  grade  of  the 
asphyxia,  although  the  cause  of  the  latter  is  of  still  greater  signifi- 
cance. Suspended  animation  which  is  not  accompanied  by  intra- 
uterine respiration  offers  the  best  prospects  for  resuscitation.  The 
chances  are  smaller  if  inspiration  has  occurred,  and  the  worst  prog- 
nosis is  afforded  by  the  occurrence  of  respiration  when  the  nose  and 
mouth  are  occluded,  on  account  of  the  graver  derangement  of  the 

*7IuTER,  "Monatsschr.  f.  Geburstk.,"  Bel.  xviii,  1862,  Supplem.  Heft,  p.  48. 
+  Schultze,  op.  cit.,  p.  127. 

t  Kristeller,  "Monatsschr.  f.  Geburtsk.,"  Bd.  xxv,  1865,  p.  321 ;  Bartscher,  Ibid.^ 
Bd.  ix,  1857,  p.  294;  Mayer,  Ibid.,  Bd.  xxv,  1865,  p.  341. 
38 


594 


THE  PATHOLOGY  OF  LABOR. 


fetal  circulation,  and  the  more  abundant  pulmonary  extravasations. 
The  presence  of  aspirated  foreign  substances  clouds  the  prognosis  by 
interfering  with  efforts  at  artificial  respiration,  and  by  acting  as  the 
exciting  cause  of  atelectasis  and  of  lobular  pneumonia.  The  prognosis 
is  also  rendered  grave  by  the  occurrence  of  intra-cranial  haemorrhages. 
The  mortality  of  asphyxiated  children  in  the  first  eight  days  after 
delivery  is,  according  to  Popjoel's  statistics,*  seven  times  greater  than 
that  of  children  born  unasphyxiated,  and  the  mortality  in  the  first 
week  in  direct  proportion  to  the  duration  and  gravity  of  the  sus- 
pended animation. 

Treatment. — Three  indications  are  to  be  fulfilled  in  the  treatment 
of  suspended  animation  :  1.  The  child  must  be  speedily  delivered,  so 
that  it  may  inspire  pure  atmospheric  air  ;  2.  The  aspirated  substances 
which  occlude  the  air-passages  must  be  removed,  in  order  that  the  air 
may  reach  the  alveoli ;  3.  If  the  asphyxia  be  so  profound  that  no 
spontaneous  respirations  occur,  the  required  air  must  be  supplied,  the 
abrogated  function  of  the  medulla  restored,  and  the  cardiac  activity 
awakened  by  artificial  respiration. 

First  Stage, — The  first  step  in  the  resuscitation  of  still-born  chil- 
dren consists  in  clearing  away  the  mucus  from  the  upper  respiratory 
passages.  This  can  pretty  generally  be  effected  with  the  little  finger. 
In  other  cases  it  may  be  advisable  to  lay  a  towel  over  the  child's  lips 
and  practice  mouth-to-mouth  insufflation.  By  this  method  little  air 
enters  the  lungs,  but  it  is  of  great  service  as  a  means  of  expelling 
mucus  from  the  nasal  passages.  If  abundant  rdles  announce  the  pres- 
ence of  fluids  in  the  larynx,  trachea,  and  bronchi,  they  should  be 
removed  by  aspiration  with  a  small  elastic  catheter  (No.  6  or  8)  passed 
through  the  glottis.  I  have  made  great  use  of  the  catheter  for  the 
purpose  mentioned,  and  believe  it  has  been  the  means  of  saving  a 
good  many  lives.  I  have  never  seen  any  harm  from  its  cautious  em- 
ployment. In  introducing  the  tube,  the  point  should  be  guided  down- 
ward by  the  index-finger  placed  behind  the  epiglottis,  at  the  upper 
posterior  border  of  the  larynx.  Only  a  very  clumsy  manipulator  could, 
as  has  been  suggested,  perforate  with  an  elastic  catheter  the  walls  of 
the  larynx  or  trachea.  By  means  of  catheterization  we  are  able  not 
only  to  clear  away  mucus  which,  inspired  into  the  smaller  bronchial 
tubes,  would  eventually  lead  to  death  from  atelectasis,  but  we  are  ena- 
bled to  transfer  air  directly  from  our  own  lungs  into  that  of  the  child. 
Usually  this  is  not  necessary.  The  stimulus  imparted  to  the  laryn- 
geal mucous  membrane  often  produces  spontaneous  respiration.  As  a 
rule,  after  the  removal  of  the  aspirated  fluids  respiration  may  be  ex- 
cited by  ordinary  cutaneous  stimuli,  such  as  sprinkling  the  face  with 
cold  water,  rubbing  the  back  with  flannel,  pouring  a  little  whisky  or 
brandy  from  a  height  upon  the  epigastrium,  flagellation  of  the  nates, 

*  POPPEL,  op.  cit,  p.  SY. 


PROLAPSE  OF  THE  FUNIS,  ETC. 


595 


or  alternately  immersing  the  child  in  hot  and  cold  water.  The  cord 
should  not  be  ligated  so  long  as  its  vessels  continue  to  pulsate,  in  order 
that  all  available  placental  blood  may  pass  into  the  fetal  circulation . 

Should  these  measures  prove  unavailing,  artificial  respiration 
must  be  resorted  to.  If  the  child  is  feeble,  and  the  beating  of  the 
heart  is  scarcely  perceptible,  it  should  be  wrapped  in  warm  clothes 
and  the  catheter  should  be  introduced.  The  obstetrician,  after  expel- 
ling the  reserve  air  from  his  lungs,  should  then  take  a  deep  inspiration, 
and  slowly  breathe  through  the  tube  into  the  lungs  of  the  child.  If 
the  catheter  has  been  properly  introduced  the  thorax  will  now  be  ob- 
served to  expand.  To  imitate  expiration,  slight  pressure  should  be 
made  upon  the  sternum,  and,  as  the  air  escapes,  it  will  be  heard  to 
make  a  blowing  noise  in  its  passage  through  the  tube.  By  patience, 
if  only  at  the  outset  the  heart  beat  at  all,  the  circulation  will  be  found 
to  become  stronger,  the  child  will  lose  its  excessive  pallor  or  lividity, 
according  to  the  stage  of  asphyxia,  and,  as  the  sensibility  is  restored, 
spontaneous  respiratory  efforts  will  be  made.  The  danger  of  injuring 
the  delicate  pulmonary  tissue,  and  of  producing  either  interstitial  or 
subpleural  emphysema  by  insufflation,  appears  to  me  to  be  exaggerated. 
The  catheter  never  exactly  fills  out  the  trachea.  Any  excess  of  air, 
therefore,  will  find  its  exit  by  the  mouth,  rather  than  through  the 
tissues. 

If  the  child  be  strong  and  well  developed,  and  the  heart  beat 
strongly,  I  can  heartily  endorse  the  following  method  recommend- 
ed by  Schultze  :  After  ligation  and  section  of  the  cord,  the  child 
should  be  grasped  in  such  a  manner  that  the  operator's  thumbs  shall 
rest,  on  either  side,  upon  the  anterior  thoracic  wall,  while  the  index- 
finger  occupies  the  axilla,  and  the  remaining  fingers  are  placed  diago- 
nally across  the  back.  The  child  is  then  allowed  to  hang  at  arm's 
length  between  the  knees  of  the  obstetrician,  its  face  being  turned  to 
the  front.  In  this  position  the  pectoral  muscles  are  made  to  draw  the 
superior  ribs  upward,  the  abdominal  muscles  draw  the  inferior  ribs 
downward,  and  the  weight  of  the  liver  causes  the  descent  of  the  dia- 
phragm. By  these  means  the  capacity  of  the  chest  is  increased  and 
inspiration  is  produced.  The  child  is  next  swung  upward,  until  the 
arms  of  the  operator  reach  an  almost  horizontal  position.  The  swing- 
ing motion  is  then  arrested,  flexion  occurs  in  the  child's  lumbar  spinal 
region,  its  head  is  directed  downward,  and  its  lower  extremities  fall 
slowly  toward  the  obstetrician,  until  the  whole  weight  of  its  body  rests 
upon  his  thumbs.  By  this  motion  the  chest  and  abdomen  are  power- 
fully compressed,  the  diaphragm  is  forced  upward,  and  an  efficient 
expiration  results,  and  any  retained  adventitious  matters  are  expelled 
from  the  air-passages.  An  inspiration  is  now  produced  by  reversing 
the  direction  of  the  swing  and  returning  the  child  to  its  former  posi- 
tion of  complete  extension,  by  which  manoeuvre  the  chest  is  caused  to 


596 


THE  PATHOLOGY  OF  LABOR. 


expand  and  tlie  diaphragm  to  descend.    This  procedure  is  repeated 
eight  or  ten  times,  at  intervals  of  a  few  seconds,  after  which  the  child 
is  placed  in  a  warm  bath,  in  order  that  its  surface  be  not  too  greatly 
refrigerated.     Should  signs  of  returning  vitality  be  now  manifested, 
alternate  immersions  in  cold  and  hot  water  may  again  be  employed. 
Should  no  spontaneous  respirations  occur,  the  swinging  may  be  repeat- 
ed, alternating  with  baths,  until  breathing  begins  or  the  heart  ceases 
to  beat.    If  the  child  be  feeble  and  the  second  stage  of  asphyxia  immi- 
nent, the  method  of  Marshall  Hall  is  preferable,  since  it  involves  less 
exposure  and  less  violent  manipulations.*    The  respiratory  motions  j 
of  the  thorax  are  produced  by  the  weight  of  the  body  and  the  elasticity  '[ 
of  the  chest.    The  child  is  first  placed  upon  its  abdomen,  and  the  \ 
expiration,  resulting  from  the  compression  of  the  thorax  by  the  body's  ji 
weight,  and  accompanied  by  expulsion  of  any  foreign  bodies  still  re-  : 
maining  in  the  air-passages,  may  be  assisted  by  pressure  with  the  hand.  'f 
The  child  is  next  turned  upon  its  side,  and,  as  lateral  compression  is  |i 
exerted,  the  thorax  expands  in  virtue  of  the  elasticity  inherent  in  its  ;| 
walls,  and  inspiration  occurs.    The  child  is  then  made  to  assume  its  i 
former  position,  and,  after  a  few  seconds,  is  turned  upon  its  other  side. 
These  alternations  of  posture  should  be  made  at  the  rate  of  fifteen  to  'J\ 
the  minute.    When  the  process  has  been  repeated  a  few  times  the  warm  ij 
bath  should  be  employed  to  prevent  undue  refrigeration  of  the  cuta-  ] 
neous  surface.    The  movements  described  should  alternate  with  the  ; 
baths  until  spontaneous  respiration  occurs  or  the  case  becomes  hope-  i 
less.    Faradization  of  the  phrenic  nerves  is  recommended  by  Pernice,t  j 
and  often  furnishes  excellent  results  ;  but,  as  a  battery  in  good  order  :j 
is  rarely  on  hand  in  a  moment  of  emergency,  the  practice  is  of  limited 
applicability.  :; 

Second  Stage. — In  the  second  stage  of  asphyxia  the  treatment  is  [ 
essentially  the  same.    After  the  removal  of  the  foreign  substances  ; 
from  the  air-passages,  artificial  respiration  is  employed.  Insufflation 
by  means  of  a  catheter  and  Marshall  Hall's  method  are  well  adapted  to 
such  cases,  since  the  child's  vitality  is  at  so  low  an  ebb  as  to  render  its 
tolerance  of  more  active  measures  problematical.    Another  mode  of 
resuscitation  suitable  for  this  stage  consists  in  artificial  respiration, 
performed  as  follows  while  the  child  is  immersed  in  warm  water  :  The  i 
child  is  placed  in  the  dorsal  decubitus,  the  back  only  being  supported  | 
by  the  operator's  hand.    The  arms,  head,  and  legs  are  allowed  to  fall 
backward.    In  this  position  inspiration  is  effected.    Expiration  is 
then  produced,  after  placing  the  child  in  a  level  position,  by  raising 
the  lower  extremity  of  the  trunk  and  by  manually  compressing  the 
thorax.    In  prematurely  delivered  asphyxiated  children  these  meth- 
ods are  inapplicable,  since  the  thoracic  walls  are  so  yielding  as  not 

*  Seydel,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxvi,  1865,  p.  284. 
\  Pernice,  "  Monatsschr.  f.  Geburtsk.,"  Bd.  xxiii,  1864,  p.  317. 


PROLAPSE  OF  THE  FUNIS,  ETC. 


597 


to  undergo  the  changes  of  form  requisite  to  the  success  of  the  meth- 
ods described.  In  such  cases  insufflation,  through  the  catheter,  follow- 
ing aspiration,  of  the  foreign  bodies  in  the  air-passages,  is  the  only 
available  treatment.  If  the  efforts  at  resuscitation  be  successful,  the 
child  must  for  the  first  few  days  after  its  birth  be  kept  particularly 
warm  and  be  regularly  nourished.* 

Collapse  and  Sudden  Death  during  Labor  and  Childbed. — We  have 
already  had  frequent  occasion  to  mention  collapse  during  or  following 
labor  as  a  sequence  of  haemorrhage,  or  of  injuries  to  which  the  genital 
passages  have  been  subjected.  Syncope  is  not  an  uncommon  result  of 
exhaustion  following  prolonged  labor,  or  even  normal  labor  in  women 
with  exceptionally  sensitive  nervous  organizations.  Again,  it  may  be 
caused  by  the  cerebral  anaemia  produced  by  the  recession  of  blood 
from  the  nerve-centers  when  the  intra-abdominal  pressure  is  suddenly 
diminished  by  the  rapid  emptying  of  the  uterus.  Temporary  syncope, 
if  followed  by  complete  restoration  of  the  normal  circulation,  has  no 
positive  prognostic  significance.  Where,  however,  the  pulse  continues 
feeble  and  rapid,  it  should  be,  even  in  the  absence  of  other  grave 
symptoms,  a  subject  of  profound  concern.  The  arteries  then  gradu- 
ally become  empty,  while  the  large  venous  trunks  fill  with  blood,  and 
the  sluggish  current  predisposes  to  the  formation  of  thrombi. 

Thrombi  owe  their  importance  to  the  disposition  they  possess  to 
disintegrate  and  form  emboli,  which  are  swept  along  by  the  circula- 
tion until  arrested  by  the  diminished  caliber  of  the  peripheral  vessels. 
A  small  clot  forming  in  the  left  side  of  the  heart  may  block  up  an 
artery  in  the  brain  or  in  either  an  upper  or  lower  limb.  The  symp- 
toms of  the  lesion  in  the  latter  case  are  the  absence  of  pulsation  in 
the  artery  below  the  thrombus,  with  pain,  coldness  of  the  surface, 
paralysis  of  the  nerves  of  motion  and  sensibility  if  the  arterial  obstruc- 
tion be  sudden  and  complete,  and  in  some  cases  gangrene  of  the  ex- 
tremity affected,  f 

Of  much  more  common  occurrence  are  venous  thrombi.  Indeed, 
it  may  be  stated  that  thrombosis  of  the  veins  furnishes  the  most  fre- 
quent cause  of  sudden  death  in  labor  and  during  the  puerperal  period. 
It  may — though  this  is  rare — occur  spontaneously  in  the  pulmonary 
artery  or  in  the  right  cardiac  cavity.  As  a  rule,  however,  the  clot- 
ting takes  place  in  the  femoral,  the  pelvic,  or  the  uterine  veins. 
Spiegelberg  I  states  that  the  emboli  which  become  detached  during  or 
shortly  after  labor  proceed  from  clots  formed  at  the  site  of  the  placen- 

*  In  what  is  known  as  Sylvester's  method,  the  child  is  placed  upon  its  back ;  then, 
by  raising  its  arms  above  the  head,  the  chest  is  expanded  and  inspiration  is  produced  ; 
while,  to  produce  expiration,  the  arms  are  lowered,  the  hands  of  the  child  are  crossed, 
and  the  elbows  are  pressed  against  the  sides  of  the  thorax. 

f  Barker,  "  The  Puerperal  Diseases,"  p.  The  enumeration  of  these  symptoms 

is  credited  to  Dr.  Barnes.  if  Spiegelberg,  loc.  cit.,  p.  661. 


598 


THE  PATHOLOGY  OF  LABOR. 


ta.  Usually  there  is  first  haemorrhage  from  partial  detachment  of  the 
placenta  ;  then  thrombus  formation  in  the  veins,  the  clots,  in  the  ab- 
sence of  uterine  retraction,  extending  from  the  open  mouths  of  the 
sinuses  in  the  direction  of  the  heart ;  and,  finally,  under  a  powerful 
contraction,  such  as  follows  oftentimes  the  rupture  of  the  membranes 
or  the  expulsion  of  the  foetus,  the  clot  is  set  adrift  from  its  moorings, 
and  is  washed  upward  through  the  vena  cava  to  the  right  side  of  the 
heart,  and  thence  to  the  branches  of  the  pulmonary  artery. 

The  symptoms  of  stoppage  in  a  large  pulmonary  vessel  are  intense 
dyspnoea,  air-hunger  (to  use  an  expressive  German  term),  fluttering 
heart-action,  a  feeble,  rapid  pulse,  a  cold  skin,  and  striking  pallor  of 
the  countenance.  Death  may  follow  in  a  few  minutes,  or,  where  the 
main  trunk  is  free,  the  more  violent  symptoms  may  in  the  course  of  a 
half -hour  subside,  to  return,  however,  with  the  slightest  movement  or 
without  apparent  cause,  the  patient  dying  in  a  few  days  from  abnor- 
mal lowering  of  the  temperature,  from  dyspnoea  and  cyanosis ;  or, 
after  a  succession  of  attacks,  the  thrombus  may  be  absorbed,  and,  as  I 
have  once  seen,  complete  recovery  may  take  place. 

A  second  and  rarer  cause  of  sudden  death  in  labor  and  childbed 
results  from  the  entry  of  air  into  the  uterine  vessels.  *  The  conditions 
for  the  occurrence  of  this  accident  are  the  access  of  air  to  the  uterine 
cavity,  and  open  communication  with  the  veins.  The  passage  of  air 
may  result  from  operations  necessitating  the  introduction  of  the  hand 
or  of  instruments  into  the  uterus.  It  is  favored  by  gaping  of  the 
vulva,  and  by  any  circumstance  which  diminishes  the  intra-abdominal 
pressure.  Thus,  it  has  been  observed  as  a  consequence  of  the  knee- 
chest  position,  the  latero-prone  position,  and  even  of  the  ordinary 
position  upon  the  side.  Aspiration  of  air  may  follow  sudden  removal 
of  intra-abdominal  pressure  after  violent  expulsive  efforts  which  have 
ended  in  rupture  of  the  membranes  or  the  precipitate  birth  of  the 
child.  Air  contained  in  the  vagina  may  be  forced  upward  into  the 
uterus  by  means  of  the  vaginal  douches,  or,  more  frequently,  air  min- 
gled with  water  may  be  conveyed  into  the  uterus  by  a  syringe  with 
imperfect  valves. 

Air  enters  the  circulation  during  pregnancy  and  labor  through  the 
sinuses  which  are  opened  by  the  separation  of  the  placenta,  in  child- 
bed by  the  accidental  detachment  of  the  thrombi  which  form  at  the 
placental  site. 

The  symptoms  of  the  entry  of  the  air  into  the  veins  are  those  of 
asphyxia.  The  diagnosis  during  life  is  to  some  extent  a  matter  of 
speculation,  as  there  are  no  direct  physical  signs  of  the  presence  of  air 
in  the  right  side  of  the  heart. 

Experimentally  it  has  been  proved  that  sudden  death  results  either 

*  For  the  literature  of  this  subject,  vide  Kezmarszky,  "  Ueber  Lufteintritt  in  die  Blut- 
bahncn  durch  den  puerperalen  Uterus,"  "  Arch.  f.  Gynaek.,  Bd.  xiii,  p.  200. 


PROLAPSE  OF  THE  FUNIS,  ETC. 


599 


when  a  Toliime  of  air  in  tlie  right  side  of  the  heart  interferes  with  the 
complete  filling  of  its  cavity,  or  when  a  column  of  air  enters  the  pul- 
monary artery  and  obstructs  the  passage  of  blood  to  the  lungs.  Air 
passing  into  the  veins  at  a  distance  from  the  heart  enters  the  lungs 
finely  subdivided,  and  forms  emboli  which  adhere  to  the  walls  of  small 
vessels,  and  produce  symptoms  of  dyspnoea,  which  often  are  of  tempo- 
rary duration.  In  obstetrical  cases  it  is  necessary,  therefore,  to  assume 
either  that  a  large  volume  of  air  has  been  forcibly  driven  into  the 
veins  or  that  a  venous  thrombus  is  simultaneously  washed  into  the 
circulation,  and  combines  with  air  emboli  to  produce  the  fatal  result 
(Spiegelberg). 

The  treatment  of  pulmonary  embolism,  whether  due  to  air  or  to  a 
disintegrated  thrombus,  is  necessarily  for  the  most  part  prophylactic. 
The  proper  precautions  for  avoiding  the  accidents  described  are  suffi- 
ciently indicated  in  the  preceding  discussions  as  to  their  etiology.  As 
the  violence  of  the  symptoms  at  the  outset  of  the  attack  is  often  out 
of  proportion  to  the  real  gravity  of  the  lesion,  warmth  should  be  ap- 
plied to  the  surface,  and  every  effort  should  be  made  to  maintain  the 
action  of  the  heart.  To  this  end,  injections  of  ether  into  the  skin  and 
of  ammonia  into  the  veins  are  to  be  counted  as  most  powerful  adju- 
vants.   If  the  storm  subsides,  the  utmost  quiet  should  be  enjoined. 

EXTRACTIOi^  OF  THE  ChILD  m  CaSE  OF  ReAL  OR  APPARENT  DeATH 

OF  THE  Mother  duri^^^g  Pregis'ancy  or  Labor. 

Death  of  the  mother  during  pregnancy  or  labor  may  be  threatened, 
or  may  actually  result,  either  suddenly  or  slowly,  from  various  morbid 
conditions  which  have  been  previously  considered.  Although  sudden 
death  of  the  mother  is  more  frequent  at  the  time  of  delivery,  in  con- 
sequence of  haemorrhage,  exhaustion,  eclampsia,  or  rupture  of  the  ute- 
rus, it  may  occur  at  any  time,  particularly  when  due  to  pulmonary  and 
cardiac  affections,  or  to  cerebral  embolism. 

It  is  our  present  object  to  consider  the  methods  of  treatment  best 
adapted  to  the  preservation  of  the  child's  life  in  those  cases  necessa- 
rily attended  by  death  of  the  mother,  and  to  the  preservation  of  both 
mother  and  child  whenever  there  is  any  probability  of  such  a  result. 
Our  inquiry  may,  therefore,  be  limited  to  those  cases  in  which  the 
child  is  unquestionably  living,  and  its  viability  undoubted.  While  the 
majority  of  recent  authors  upon  this  subject  have  recognized  the  pro- 
priety of  adopting  prompt  measures  for  the  immediate  extraction  of 
the  child  after  the  mother's  decease,  the  same  unanimity  has  not  pre- 
vailed either  in  regard  to  the  propriety  of  operative  interference  before 
the  mother's  death,  or  as  to  the  most  appropriate  methods  of  opera- 
tion. Schroeder  *  is  content  with  the  statement  that,  in  cases  of  ma- 
ternal demise  during  parturition,  efforts  should  be  made  to  extract 
*  Schroeder,  "Lehrbuch,"  p.  '712. 


600 


THE  PATHOLOGY  OF  LABOR. 


the  foetus  per  vias  naturales  by  version  or  the  forceps.  In  the  event 
of  failure  to  accomplish  delivery  by  this  method,  he  advises  immediate 
resort  to  the  Csesarean  section.  Spiegelberg  *  recommends  the  Caesa- 
rean  section  for  all  cases  of  maternal  death,  excepting  those  occurring 
in  the  second  stage  of  labor,  as  the  surest  method  of  preserving  fetal 
life.  He  makes  no  provision  for  those  cases  in  which  the  mothers  are 
apparently  dead,  although  actually  in  a  state  of  synco]3e  or  asphyxia, 
recommends  the  Oaesarean  section,  even  in  cases  of  impending  death  of 
the  mother,  in  the  child's  interest,  and  disparages  elforts  at  extraction 
through  the  natural  passages.  Duer  f  concludes  {a)  that  no  operative 
procedure  should  be  undertaken  until  there  is  absolute  certainty  of 
the  mother's  death  ;  {b)  that,  death  of  the  mother  being  assured,  the 
Csesarean  section  should  be  performed  with  dispatch  if  the  fetal  head 
be  above  the  pelvic  brim  ;  (c)  that,  if  the  head  have  engaged  in  the 
brim,  the  question  of  resort  to  the  Oaesarean  section  or  to  extraction 
per  vias  naturales  becomes  debatable.  He  condemns  the  practice, 
attributed  by  him  to  Rizzoli  and  Esterle,  of  resorting  to  forced  deliv- 
ery when  the  mother's  death  is  imminent. 

One  of  the  most  recent  and  comprehensive  articles  on  the  subject 
of  artificial  delivery  per  vias  naturales  is  that  of  Thevenot,J  who, 
referring  its  original  introduction  to  Schenk  and  Rigaudeaux,  and  its 
development  to  Rizzoli,  Heymann,  and  Depaul,  ardently  advocates  its 
adoption,  to  the  exclusion  of  the  Oaesarean  section.  This  method  he 
declares  to  be  applicable  (a)  to  those  cases  with  normal  pelvic  confor- 
mation in  which  the  mother  is  dead,  the  labor  somewhat  advanced,  the 
OS  dilated  or  dilatable,  and  the  head  at  the  superior  strait ;  (^)  to  cases 
in  which  labor  was  only  commencing,  or  had  not  begun  at  the  time  of 
death ;  (c)  to  cases,  frequently  occurring,  according  to  the  author,  of 
apparent  death  of  the  mother  (her  real  condition  being  that  of  syn- 
cope), whether  labor  had  or  had  not  begun  at  the  time  of  her  apparent 
decease  ;  and  (d)  to  cases  of  impending  maternal  death.  Thevenot's 
arguments  in  favor  of  the  method  of  treatment  under  consideration 
are,  that  the  operation  may  be  more  promptly  resorted  to  than  the 
Oaesarean  section,  the  preparations  for  and  hesitations  about  which 
frequently  occasion  fatal  delays  ;  that  it  is  of  less  vital  importance 
that  the  death  of  the  mother  be  positively  ascertained  than  in  cases  of 
Oaesarean  section  ;  that  it  is  a  less  repulsive  proceeding ;  that  the 
results  are  better  than  in  the  Oaesarean  section  ;  that  the  method  is 
not  productive  of  medico-legal  complications  ;  and  that  it  affords  a 
numerous  class  of  parturient  women,  who  are  only  apparently  dead,  a 

*  Spiegelberg,  "  Lehrbuch,"  p.  269. 

f  Duer,  "Am.  Jour,  of  Obstet.,"  January,  IS'ZG,  p.  10. 

\  Thevenot,  "  De  I'acc.  artif.  par  les  voies  nat.  substit.  \  I'operation  c6sar,  post  mor- 
tern;'  "  Ann.  de  Gynec,"  tome  x,  October,  1878,  p.  257  ;  November,  1878,  p.  339;  De- 
cember, 1878,  p.  412. 


PROLAPSE  OF  THE  FUNIS,  ETC. 


601 


far  better  chance  of  recovery  than  does  the  Cassarean  section.  Theve- 
not  cites  fifteen  cases  of  accoucliement  force  employed  upon  women  at 
the  point  of  death,  in  which  thirteen  infants  were  ahve  at  birth,  and  six 
lived  permanently.  Five  of  the  fifteen  mothers,  who  were  apparently 
moribund,  recovered,  and  in  three  other  cases  the  original  diseases  were 
retarded,  and  their  most  distressing  symptoms  temporarily  relieved. 

Tympanites  Uteri. — If  air  enters  the  uterine  cavity  previous  to  the 
birth  of  the  child,  the  dangers  are  not  confined  to  its  passage  into  the 
venous  circulation.  Even  when  this  latter  accident  does  not  occur, 
the  patient's  condition  in  a  lingering  labor  is  perilous  in  the  extreme. 
The  essential  condition  for  the  admission  of  air  is  rupture  of  the  mem- 
branes. As  a  result  in  many  though  not  in  all  cases,  untimely  respir- 
atory efforts  are  excited  in  the  child.  In  very  rare  instances  it  is 
said  that  the  cry  of  the  child,  vagitus  liter inus,  has  been  heard  within 
the  uterus.  Death  speedily  follows  premature  respiration,  and,  under 
the  combined  influence  of  air,  heat,  and  moisture,  decomposition 
rapidly  develops.*  The  gases  generated  by  putrefaction  are  some- 
times of  enormous  volume,  and  the  uterus  furnishes  a  tympanitic 
resonance  upon  percussion.  As  a  result  of  prolonged  labor,  of  the  dis- 
tention of  the  uterine  walls,  and  of  septic  poisoning,  the  pains  become 
feeble  and  the  patient  suffers  from  dyspnoea,  owing  to  the  pressure 
upon  the  diaphragm  by  the  enlarged  uterus  and  the  colon,  which  like- 
wise is  found  distended  with  gases.  A  stinking  discharge,  sometimes 
mingled  with  gas-bubbles,  is  always  present. 

The  prognosis  depends  upon  the  intensity  of  the  process  and  the 
length  of  time  allowed  to  elapse  before  operative  measures  are  em- 
ployed to  remove  the  source  of  danger.  Of  sixty-four  women,  accord- 
ing to  Staude's  report,  thirty-two  died,  eighteen  had  severe  puerperal 
affections,  and  only  fourteen  recovered  without  further  complications. 
The  indications  for  treatment  are,  to  extract  the  child  as  soon  as  prac- 
ticable when  air  has  once  entered  the  uterine  cavity,  to  wash  out  the 
uterus  with  disinfectant  fluids,  to  use  all  available  means  to  secure 
continued  retraction  of  the  uterus,  and  to  follow  every  antisej)tic  pre- 
caution during  the  puerperal  period. 

*  Staude  found  putrefactive  changes  developed  in  foetuses  born  from  three  to  twen- 
ty-one hours  after  the  access  of  air  to  the  uterus.  "  Ueber  den  Eintritt  von  Luft  in  die 
Gebarmutter,"  "  Ztschr.  f.  Geburtsh.  und  Gynaek.,"  Bd.  iii,  p.  204. 


602 


DISEASES  OF  CHILDBED. 


DISEASES  OF  CHILDBED. 


CHAPTER  XXXV. 

PUERPERAL  FEVER. 

Frequency. — Pathological  anatomy. — Endocolpitis  and  endometritis. — Metritis  and  para- 
metritis.— Pelvic  and  diffused  peritonitis. — Phlebitis  and  phlebo-thrombosis. — Nature 
of  puerperal  fever. — Clinical  history. — Symptoms  of  endometritis  and  endocolpitis ; 
of  parametritis  and  perimetritis  ;  of  general  peritonitis ;  of  septicaemia  lymphatica ; 
of  septicaemia  venosa  ;  of  pure  septicaemia. 

Frequency. — In  a  careful  search  through  the  records  preserved  by 
the  Health  Department  of  New  York  City,  I  found  that  from  1868 
to  1875  inclusive  the  total  number  of  deaths  for  the  nine  years  was 
248,533.  Of  these,  3,342  were  from  diseases  complicating  pregnancy, 
from  the  accidents  of  child-bearing,  or  from  diseases  of  the  puerperal 
state  ;  or,  in  other  words,  one  in  seventy-five  (1:  75)  of  all  the  deaths 
occurring  during  that  period  was  the  result  of  the  performance  of 
what  we  are  in  the  habit  of  regarding  as  a  physiological  function. 

The  deaths  from  miscarriage,  from  shock,  from  prolonged  labor, 
from  instrumental  delivery,  from  convulsions,  from  haemorrhage,  from 
rupture  of  the  uterus,  and  from  extra-uterine  pregnancy,  and  deaths 
from  eruptive  fevers,  from  phthisis,  and  from  inflammatory  non-puer- 
peral affections  complicating  childbirth,  made  a  total  of  1,395,  or 
about  42  per  cent,  of  the  entire  number.  The  remaining  1,947  cases, 
variously  reported  as  puerj)eral  fever,  puerperal  peritonitis,  metro- 
peritonitis, phlebitis,  phlegmasia  dolens,  pyaemia,  and  septicaemia, 
represent  the  very  serious  sacrifice  of  life  resulting  from  inflamma- 
tory processes  which  have  their  starting-point  in  the  generative  appa- 
ratus. If  we  apply  the  general  term,  puerperal  fever,  to  this  class  of 
cases,  it  will  be  seen  that  the  malady  is  the  cause  of  nearly  of  all 
the  deaths  occurring  in  the  city.  The  actual  number  of  births  for  the 
nine  years  in  question  was  roughly  estimated  at  284,000,*  an  estimate 
erring  upon  the  side  of  liberality.  The  total  number. of  deaths  to  the 
entire  number  of  confinements  was,  then,  at  least  in  the  proportion  of 
one  to  eighty-five  (1  :  85),  or,  from  puerperal  fever  alone,  in  the  propor- 

*  This  estimate  was  based  upon  the  assumption  that  the  natural  birth-rate  is  33  to 
the  1,000,  a  proportion  believed  by  the  statisticians  of  the  Board  of  Health  to  be  approxi- 
raatively  correct,  though  probably  somewhat  in  excess  of  the  reality.  P.  Osterloh  has 
recently  stated  that  my  statistics  were  computed  in  so  arbitrary  a  manner  as  to  render 
deductions  from  them  valueless.  In  this,  however,  he  is  mistaken.  The  most  conscien- 
tious care  was  taken  in  their  preparation ;  wherever  the  possibility  of  error  existed,  the 
fact  was  distinctly  indicated ;  and  all  calculations  were  made  in  such  a  way  that  whatever 
corrections  might  be  required  would  strengthen  the  conclusions. 


PUERPERAL  FEVER. 


603 


tion  of  one  to  one  hundred  and  forty-six  (1  : 146).  Now,  if  we  add 
to  these  naked  statistics  the  fact  that  the  average  number  of  confine- 
ments to  each  woman  during  the  child-bearing  period  is  from  four 
to  five,  it  will  become  apparent  that  the  community  has  a  right  to 
demand  of  every  practicing  accoucheur  a  familiarity  with  what  is 
definitely  known  concerning  the  nature  and  prevention  of  a  scourge 
which,  according  to  the  statistics  of  the  Puerperal  Fever  Commis- 
sion,"* appointed  by  the  Berlin  Society  of  Obstetrics  and  Gynaecolo- 
gy, destroys  nearly  as  many  lives  as  either  small-pox  or  cholera.  But 
puerperal  fever  differs  from  either  small-pox  or  cholera  in  that  the 
latter  presses  largely  upon  the  aged  and  the  vsry  young,  while  the  for- 
mer gathers  its  victims  exclusively  from  a  selected  class,  viz.,  from 
women  in  adult  life,  the  mothers  of  families  whose  loss,  as  a  rule,  is 
a  public  as  well  as  a  private  calamity. 

Before  proceeding  to  consider  the  nature  of  puerperal  fever,  it  is 
desirable  to  first  recall  the  anatomical  lesions  with  which  it  is  associ- 
ated. These,  it  will  be  found,  are  for  the  most  part  inflammatory 
processes  having  their  starting-point  in  injuries  of  the  genital  passage 
produced  by  parturition. 

The  Pathological  Anatomy  of  Puerperal  Fever. — The  lesions  con- 
nected with  puerperal  fever  are  so  various  that  the  student  will  find 
it  convenient  to  classify  them  according  as  they  are  situated  in  the 
mucous  membrane  of  the  utero-vaginal  canal,  the  parenchyma  of  the 
uterus,  the  jpelvic  cellular  tissue,  the  peritonaeum,  the  lymphatics,  or 
the  veins.  Not,  indeed,  that  such  an  arrangement  is  strictly  in  accord- 
ance with  clinical  experience — as  a  rule,  the  inflammatory  processes 
are  rarely  limited  to  a  single  tissue — but  because  the  prognosis  and 
treatment  are  determined  in  great  measure  by  the  tissue  system  which 
is  predominantly  affected.  The  significance  of  puerperal  inflamma- 
tions, wherever  seated,  likewise  depends  upon  whether  they  are  local 
and  circumscribed,  or  whether  they  present  a  spreading  character. 

Personally  I  have  found  the  following  classification  of  Spiegel- 
berg  f  of  great  utility  as  a  means  of  keeping  in  mind  the  principal 
points  to  which  inquiry  should  be  directed  in  estimating  the  signifi- 
cance of  the  febrile  conditions  of  childbed  : 

1.  Inflammation  of  the  Genital  Mucous  Membrane. — Endocolpitis 
and  endometritis. 

a.  Superficial. 

h.  Ulcerative  (diphtheritic). 

2.  Inflammation  of  the  Uterine  Parenchyma,  and  of  the  Subserous 
and  Pelvic  Cellular  Tissue. 

a.  Exudation  circumscribed. 

*  "  Ztschr.  f.  Geburtsh.  und  Gynaek.,"  Bd.  iii,  p.  1. 

f  Spiegelberg,  "  Ueber  das  Wesen  des  Puerperalfiebers,"  Volkmann's  "  Samml.  klin. 
Vortr.,"  No.  3. 


604 


DISEASES  OF  CHILDBED. 


1).  Phlegmonous,  diffused ;  with  lymphangitis  and  pyaemia  (lym- 
phatic form  of  peritonitis). 

3.  Liflammation  of  the  Peritonceum  covering  the  Uterus  and  its 
Appendages. — Pelvic  peritonitis  and  dilfused  peritonitis. 

4.  Phlebitis  Titer ina  and  Para-uterina  with  formation  of  thrombi, 
embolism,  and  pyaemia. 

5.  Pure  Septicmmia. — Putrid  absorption. 

Endocolpitis  and  Endometritis. — In  the  superficial,  catarrhal  form 
of  inflammation  the  mucous  membrane  of  the  vagina  is  swollen  and 
hyperaemic,  the  papillae  are  enlarged,  and  the  discharge  is  profuse  ;  in 
the  vaginal  portion  of  the  cervix  the  labia  uterina  are  oedematous  and 
covered  with  granulations  which  bleed  at  the  slightest  touch  ;  in  the 
cavity  of  the  body  there  are  increased  transudation  of  serum  and  abun- 
dant pus  formation.  The  deep  structures  of  the  uterus  are  usually 
not  aifected.  Sometimes  the  inflammation  extends  to  the  tubes — sal- 
pingitis— or,  passing  outward  through  the  fimbriated  extremities,  it 
may  spread  over  the  adjacent  peritonaeum. 

The  small  wounds  at  the  vaginal  orifice  are  at  times  converted  into 
ulcers  with  tumefied  borders.  These  so-called  puerperal  ulcers  "  are 
covered  with  a  greenish-yellow  layer.  They  are  associated  usually 
with  oedematous  swelling  of  the  labia.  Under  favorable  sanitary  con- 
ditions the  deposit,  which  consists  in  the  main  of  pus-cells,  clears  away 
and  the  surface  heals  by  granulation.  The  ulcerative  form  of  inflam- 
mation is  very  rare  outside  of  crowded  hospitals. 

Diphtheritic  ulcers  are  situated  with  greatest  frequency  in  the 
neighborhood  of  the  posterior  commissure,  or  around  the  vaginal 
orifice.  In  rarer  instances  they  are  found  upon  the  anterior  wall  and 
in  the  fornix  of  the  vagina,  in  the  cervix,  and  upon  the  site  of  the 
placenta.  The  borders  are  red  and  jagged  ;  the  base  is  covered  with 
a  yellowish-gray,  shreddy  membrane  ;  the  secretion  is  purulent,  alka- 
line, and  fetid  ;  and  the  adjacent  tissues  are  oedematous.  From  the 
vulva  they  may  extend  to  the  perinaeum,  or  pursue  a  serpiginous  course 
down  the  thighs.  In  the  uterus  and  about  the  cervix  they  vary  as 
regards  size,  and  are  either  of  a  rounded  shape  or  form  narrow  bands. 
The  intervening  portions  of  tissue  which  have  not  undergone  destruc- 
tive changes  swell  and  stand  out  in  strong  relief.  Where  the  entire 
inner  surface  has  become  necrosed,  it  is  often  covered  with  a  smeary, 
chocolate-brown  mass  which,  when  washed  away  with  a  stream  of 
water,  leaves  exposed  either  the  deepest  layer  of  the  mucous  mem- 
brane or  the  underlying  muscular  structures. 

The  dift'erence  between  the  superficial  ulcerations  of  the  genital 
canal  and  the  diphtheritic  form  involving  destruction  of  the  deeper 
tissues  is  due  to  the  presence  in  the  latter  of  minute  organisms  termed 
micrococci,  the  relations  of  which  to  puerperal  infection  will  be  con- 
sidered in  a  subsequent  division. 


PUERPERAL  FEVER. 


605 


Metritis  and  Parametritis, — In  ulcerative  endometritis,  and  even 
in  the  extreme  catarrhal  form,  the  parenchyma  of  the  uterus  likewise 
becomes  involved.  The  changes  which  are  designated  under  the  term 
metritis  consist  in  the  first  place  of  oedematous  infiltration  of  the  tis- 
sues. As  a  consequence,  the  organ  contracts  imperfectly,  and  becomes 
soft  and  flabby,  so  that  sometimes,  upon  post-7nortem  examination,  it 
bears  the  imprint  of  the  intestines. 

In  diphtheritic  endometritis  the  gangrenous  process  may  attack 
the  muscular  tissue,  and  give  rise  to  losses  of  muscular  substance,  a 
condition  known  as  necrotic  endometritis,  or  putrescence  of  the  uterus. 

Inflammatory  changes  are  rarely  lacking  in  the  intermuscular  con- 
nective tissue,  which  exhibits  in  places  serous  or  gelatinous  infiltration 
with  afterward  pus  formation,  and  with  here  and  there  small  abscesses. 
The  sero-purulent  infiltration  of  the  connective  tissue  is  specially 
marked  beneath  the  peritoneal  covering  of  the  uterus  either  behind  or 
along  the  sides  at  the  attachment  of  the  broad  ligaments.  In  the  same 
situations  the  lymphatics,  which  normally  are  barely  perceptible  to  the 
naked  eye,  are  sometimes  enlarged  to  the  size  of  a  quill,  and  are  char- 
acterized by  varicose  dilatations  occurring  singly  or  presenting  a 
beaded  arrangement.  In  the  substance  of  the  uterus  the  dilated  ves- 
sels are  liable  to  be  mistaken  for  small  abscesses.  The  pus-like  sub- 
stance contained  in  the  lymphatics  is  com^Dosed  of  pus-cells  and  of 
micrococci.  From  the  cellular  tissue  surrounding  the  vagina,  or  that 
beneath  the  peritoneal  covering  of  the  uterus,  the  inflammation  may 
spread  by  contiguity  of  tissue  between  the  folds  of  the  broad  ligament, 
and  thence  pass  upward  to  the  iliac  fossae.  Usually  the  process  is  uni- 
lateral. After  the  inflammation  has  crossed  the  linea  terminalis  it 
may  take  a  forward  direction  above  the  sheath  of  the  ilio -psoas  mus- 
cle to  Poupart's  ligament,  or  it  may  creep  upward,  following  the  course, 
according  to  the  side  afl'ected,  of  the  ascending  or  descending  colon  to 
the  region  of  the  kidney.  It  is  rare  for  inflammation  of  the  cellular 
tissue  to  travel  around  the  bladder  to  the  front.  In  such  cases  it  pur- 
sues its  course  between  the  walls  of  the  bladder  and  the  uterus,  and 
along  the  round  ligament  to  the  inguinal  canal.  In  a  few  cases  the 
cellulitis  mounts  above  Poupart's  ligament,  between  the  peritonaeum 
and  the  abdominal  wall. 

The  course  of  the  inflammation  is  not  simply  fortuitous,  but  follows  pre- 
arranged pathways  in  the  connective  tissue.  Konig*  and  Schlesingerf  have 
shown  that,  when  air,  water,  or  liquefied  glue  is  forced  into  the  cellular  tissue 
between  the  broad  ligaments,  the  injected  mass  has  a  tendency  to  invade  the 
iliac  fossae.  In  Schlesinger's  experiments,  if  the  cannula  of  the  syringe  was  in- 
serted into  the  anterior  layer  of  the  broad  ligament,  the  glue  spread  between  the 
folds  to  the  abdominal  end  of  the  Fallopian  tube ;  thence  following  the  track 

*  KoNiG,  "Arch,  der  Ileilkunde,"  3  Jahrg.,  1862. 
f  ScHLESiNGER,  "  Gynaekologischc  Studien,"  No.  1. 


606 


DISEASES  OF  CHILDBED. 


of  the  vessels,  it  passed  to  the  linea  terminalis  ;  and  finally  mounted  upward  along 
the  colon,  or  swept  forward  to  Poupart's  ligament  until  the  advance  was 
stopped  at  the  outer  border  of  the  round  ligament.  If  the  injection  was  made 
to  the  side  of  the  cervix  through  the  posterior  layer  at  the  junction  of  the  cervix 
and  the  body,  the  posterior  layer  gradually  bulged  out,  the  peritonaeum  was  lifted 
from  the  side-wall  of  the  pelvis,  and  the  glue  passed  beyond  the  vessels  to  reach 
the  iliac  fossa.  If  the  injection  was  made  to  the  side  of  the  cervix  through  the 
anterior  layer,  the  glue  passed  between  the  bladder  and  the  uterus,  and  forward 
along  the  round  ligament  to  the  inguinal  canal,  while  another  portion  of  the  fluid 
passed  between  the  layers  of  the  broad  ligament,  and  reached  the  peritoneal 
covering  of  the  side-walls  behind  the  round  ligament.  If  the  injection  was  made 
in  the  median  line  in  a  peritoneal  fold  of  Douglas's  cul-de-sac^  the  fluid  traveled 
forward  upon  one  side  along  the  round  ligament  and  thence  to  the  posterior 
wall  of  the  bladder. 

The  term  parametritis,  introduced  into  use  by  Virchow,  is,  prop- 
erly speaking,  limited  to  inflammation  of  the  connective  tissue  im- 
mediately adjacent  to  the  uterus,  the  older  one  of  pelvic  cellulitis 
furnishing  a  more  comprehensive  designation  for  cases  where,  as  a 
consequence  of  a  progressive  advance  from  the  point  ^f  departure  in 
the  genital  canal,  the  remoter  regions  have  likewise  been  invaded. 
Connective-tissue  inflammation  presents,  as  the  first  essential  charac- 
teristic, an  acute  oedema,  the  fluid  which  fills  the  gaps  and  interspaces 
consisting  of  transuded  serum  rendered  opaque  by  the  presence  of  pus- 
cells,  or  possessing  a  gelatinous  character.  In  the  mild,  uncomplicated 
cases  the  oedema  disappears  rapidly.  Where  the  cell-collections  are  of 
moderate  extent,  the  entire  process  may  vanish  without  leaving  a  trace 
of  its  existence.  If  the  cell-elements,  on  the  other  hand,  are  present  in 
great  abundance,  they,  as  a  rule,  first  undergo  fatty  degeneration, 
and,  after  the  absorption  of  the  fluid  portion,  form  a  hard  tumor  com- 
posed of  a  fine  granular  detritus,  which,  under  favorable  circumstances, 
likewise  after  a  few  weeks  becomes  absorbed.  In  rare  cases  abscess 
formation  in  the  tumor  results. 

In  the  parametritis  resulting  from  septic  infection,  especially  in 
cases  complicated  by  diphtheritis,  the  tissues  seem  as  if  soaked  with 
dirty  serum,  and  contain  scattered  yellowish  deposits,  which  soon  pre- 
sent, even  to  the  naked  eye,  the  appearance  of  pus-collections.  This 
sero-purulent  oedema  is  always  associated  with  lymphangitis,  the  lym- 
phatic vessels  possessing  varicose  dilatations  and  beaded  arrangements 
similar  to  those  already  described  in  the  uterine  tissue.  The  foregoing 
changes  are  most  distinct  in  the  firm  connective  tissue  adjacent  to  the 
uterus  and  at  the  hilum  of  the  ovary,  while  they  are  less  clearly  traced 
in  the  looser  structure  of  the  broad  ligament  (Spiegelberg). 

In  favorable  cases  the  inflammation  is  circumscribed,  or  at  least  is 
limited  by  the  nearest  lymphatic  glands.  In  cases  of  intense  infection 
it  spreads  rapidly,  and  justifies  the  title  bestowed  upon  it  by  Virchow 
of  parametritic  malignant  erysipelas. 


PUERPERAL  FEVER. 


607 


Pelvic  and  Diffused  Peritonitis. — Inflammation  of  the  pelvic  peri- 
tonaeum may  result  from  severe  attacks  of  catarrhal  endometritis,  the 
inflammatory  process  either  traversing  the  uterine  tissue  or  passing 
through  the  Fallopian  tubes  to  the  adjacent  serous  membrane  ;  or 
it  may  proceed,  secondarily,  from  the  stretching  and  irritation  occa- 
sioned by  an  associated  parametritis. 

As  a  rule,  pelvic  peritonitis  is  not  attended  with  much  exudation. 
The  latter  is  situated  upon  the  folds  of  the  peritonaeum  limiting  the 
cul'de-sac  of  Douglas,  upon  the  ovaries,  and  upon  the  broad  ligaments. 
In  favorable  cases  it  consists  of  fibrinous  flakes  and  fluid  pus.  If  the 
latter  is  abundant,  it  may  become  encysted  by  the  formation  of  adhe- 
sions between  the  pelvic  organs. 

General  peritonitis  may  result  from  the  extension  of  a  pelvic  j^eri- 
tonitis,  or  from  the  transport  of  poison  through  the  lymphatics  into 
the  peritoneal  sac.  In  the  first  case  the  entire  peritonaeum  is  injected, 
and  the  contents  of  the  abdominal  cavity  are  loosely  bound  together 
by  pseudo-membranes,  composed  of  pus  and  coagulated  fibrine.  The 
intestines  are  at  the  same  time  distended  and  the  diaphragm  is  pushed 
upward.  In  the  so-called  peritonitis  lymphatica,  the  inflammatory 
symptoms  are  at  the  outset  lacking.  The  abdominal  cavity  is  found 
filled  with  a  thin,  stinking,  greenish  or  brownish  fluid,  composed  of 
serum  and  micrococci.  The  intestines  are  lax  and  oedematous,  and 
the  muscular  structures  are  paralyzed,  with  resulting  tympanitic  dis- 
tention. The  peritoneal  covering  of  the  intestines  is  devoid  of  luster, 
and  covered  with  injected  patches,  or  is  stained  of  a  dark-brown  color. 
Death  often  ensues  before  the  occurrence  of  exudation. 

Septic  forms  of  pelvic  inflammation  are  often  associated  with  oo- 
phoritis, the  dilated  lymphatics  either  extending  to  the  substance  of 
the  ovaries,  where  they  may  lead  to  the  production  of  small  abscesses, 
or,  as  a  result  of  blood  dissolution,  the  organs  become  soft,  pulpy,  and 
infiltrated  with  discolored  serum,  and  present  haemorrhagic  spots  dis- 
tributed over  the  surface. 

Phlebitis  and  Phlebo-Thrombosis. — The  formation  of  thrombi  in 
the  uterine  and  pelvic  veins  is  sufficiently  common  during  the  puer- 
peral period.  The  coagulation  may  result  from  compression  or  from 
enfeeblement  of  the  circulation.  A  predisposition  to  its  occurrence  is 
created  by  relaxation  of  the  uterine  tissue.  A  normal  thrombus  is  in 
itself  harmless.  In  time  it  becomes  organized,  and  the  occluded  ves- 
sel is  converted  into  a  connective-tissue  cord,  or  a  channel  may  form 
through  it  which  permits  the  passage  of  the  blood-stream.  When, 
however,  pus  or  septic  matters  obtain  access  to  a  thrombus,  it  under- 
goes rapid  disintegration,  and  the  particles  get  swept  away  into  the 
circulation  until  arrested  in  the  ramifications  of  the  pulmonary  artery. 
Wherever  these  poisoned  emboli  happen  to  lodge,  inflammation  is  set 
up  in  the  adjacent  tissues,  and  abscesses  result  (pyaemia  multiplex). 


608 


DISEASES  OF  CHILDBED. 


Sometimes  countless  collections  of  pus  may  form  in  the  lungs.  Less 
commonly  abscesses  are  found  in  the  liver  or  spleen,  originating  either 
from  emboli  which  have  already  made  the  pulmonary  circuit,  or  from 
thrombi  in  the  pulmonary  veins. 

Inflammation  of  the  veins  (phlebitis)  sometimes  occurs,  when  the 
vessels  have  to  traverse  tissues  in  or  near  the  uterus  infiltrated  with 
purulent  or  septic  materials.  The  endothelium  then  undergoes  prolif- 
eration, and  thrombosis  is  produced.  Phlebitic  thrombi  do  not  neces- 
sarily break  down,  and  may  in  that  case  act  as  a  barrier  to  the  progres- 
sion of  septic  germs  into  the  circulation  (Spiegelberg).  As  a  rule, 
however,  under  the  influence  of  inflammation  and  infection,  they  be- 
come converted  into  puriform  masses. 

The  thrombi  grow  by  accretion  in  the  direction  of  the  heart. 
They  may  extend  from  the  uterus  through  the  internal  spermatic,  or 
through  the  hypogastric  and  common  iliac  veins,  to  the  vena  cava. 
Sometimes  the  thrombus  may  be  traced  back  to  the  placental  site. 

Septicaemia. — From  these  local  conditions,  sooner  or  later,  secondary 
affections  develop  in  distant  organs.  The  general  affection  is,  in  great 
part  at  least,  likewise  of  local  origin.  Sometimes,  however,  where 
the  poison,  which  enters  the  system  through  the  lymphatics  and  veins, 
is  very  active  and  abundant,  death  may  follow  from  acute  septicsemia 
before  the  changes  in  the  sexual  organs  have  had  time  to  develop.  The 
fatal  result  in  these  cases  is  probably  due  to  paralysis  of  the  heart. 
After  death,  post-mortem  decomposition  rapidly  sets  in,  the  blood  is 
sticky,  and  swelling  is  found  in  the  various  parenchymatous  organs. 

The  secondary  affections  consist  in  the  metastatic  abscesses  already 
noticed  as  produced  by  infected  emboli,  in  circumscribed  purulent 
collections  due  to  the  conveyance  of  septic  materials  into  the  blood- 
current  through  the  lymphatics,  in  ulcerative  endocarditis,  in  inflam- 
mations of  the  pleura,  the  pericardium,  and  the  meninges,  and  in  puru- 
lent inflammation  of  the  joints. 

A  study  of  the  nature  of  puerperal  fever  will  best  show  how  inti- 
mately these  seemingly  distinct  processes  are  linked  together. 

The  Nature  of  Puerperal  Fever.— It  has  now  passed  beyond  the 
domain  of  dispute  that  puerperal  fever  is  an  infectious  disease,  due,  as 
a  rule,  to  the  septic  inoculation  of  the  wounds  which  result  from  the 
separation  of  the  decidua  and  the  passage  of  the  child  through  the 
genital  canal  in  the  act  of  parturition. 

To  maintain  this  definition  it  is,  however,  necessary  to  group  by 
themselves  cases  of  childbed-fever  dependent  upon  causes  which  are 
operative  in  the  non-puerperal  condition,  though  the  latter  imparts  to 
these  causes  oftentimes  an  exceptional  activity  and  virulence.  In  this 
category  are  to  be  placed  scarlatina,  typhus,  typhoid,  and  malarial 
fevers.  It  is  to  be  borne  in  mind  that  the  zymotic  fevers  may  pro- 
voke in  the  puerperal  woman  the  same  inflammatory  lesions  that  are 


PUERPERAL  FEVER. 


609 


commonly  associated  with  puerperal  fever.*  This  is  in  accordance 
with  the  well-known  surgical  experience  that  a  febrile  paroxysm  from 
any  cause  exerts  an  unfavorable  influence  upon  a  wounded  surface. 
Olshausen  f  has,  however,  shown  that  pelvic  inflammations  and  peri- 
tonitis are  somewhat  rare  in  scarlatina  complicating  the  puerperal  state. 

Again,  instances  of  puerperal  inflammations  and  febrile  conditions 
are  sometimes  observed  in  which  the  symptoms  of  blood-poisoning  are 
apparently  absent,  or  are  present  only  to  a  subordinate  extent,  and  as 
a  late  feature  of  the  disease. 

As  illustrations  of  this  class  may  be  mentioned  :  1.  Cases  of  catar- 
rhal endometritis  due  to  errors  of  diet  and  exi^osure.  Indeed,  I  have 
frequently,  in  hospital  practice,  been  able  to  trace  severe  cases  of  cel- 
lulitis, pelvic  peritonitis,  and  general  peritonitis  occurring  in  the  win- 
ter season,  to  the  patient  getting  out  of  bed  drij^ping  with  perspiration, 
and  clad  only  in  a  night-dress,  and  going  thus  barefooted  over  a  cold, 
uncarpeted  floor  to  the  water-closet.  2.  Cases  of  puerperal  disorders 
proceeding  from  emotional  causes,  the  nervous  system  furnishing  the 
first  impulse  to  the  disturbed  action.  3.  Cases  of  excessive  vulnera- 
bility in  non-pregnant  women ;  individuals  are  sometimes  found  so 
susceptible  that  a  parametritis  follows  a  simple  application  of  the  tinct- 
ure of  iodine  to  the  cervix.  4.  Cases  of  pelvic  peritonitis  starting 
from  old  intra-peritoneal  adhesions.  5.  Cases  of  peritonitis  and  retro- 
peritoneal inflammations  secondary  to  ulcerative  processes  in  the  cae- 
cum or  the  descending  colon.  This  condition  is  apt  to  be  marked 
during  pregnancy,  but  starts  into  activity  during  childbed  as  a  conse- 
quence of  fecal  accumulation  or  of  excessive  purgation. 

It  is  by  no  means  easy  to  decide  as  to  the  position  of  local  inflam- 
mations following  lacerations  of  the  cervix,  and  the  bruising  or  crush- 
ing the  soft  parts  in  long  or  instrumental  labors.  Similar  circum- 
scribed inflammations  in  other  situations  are  attributed  to  ordinary 
reaction  from  traumatic  injuries.  It  is  not,  for  instance,  customary 
to  ascribe  a  phlegmon  of  the  breast  proceeding  from  a  lesion  of  the 
nipple  to  septic  infection.  At  the  same  time  the  marvelous  absence 
of  heat,  pain,  redness  and  swelling  in  wounds  treated  in  strict  accord- 
ance with  the  principles  of  Lister,  the  very  slight  reaction  when  the 
atmosphere  is  pure,  and  the  severity  of  these  symptoms  in  crowded 
hospitals,  all  tend  to  strengthen  the  belief  that  even  the  simplest  in- 
flammations proceeding  from  wounds  owe  their  origin  in  great  part  to 
septic  germs. 

That,  however,  the  infectious  diseases  of  childbirth  are  of  septic 
origin,  there  is  now  abundant  evidence.  The  question  of  the  identity 
of  puerperal  fever  and  septicaemia  is  largely  one  of  definition.    It  is  a 

*  IIervieux,  "Traite  clinique  et  pratique  des  maladies  puerperales,"  pp.  1073  et  seq. 
f  Olshausen,  "  Untersuchungen  Ubcr  die  Complication  des  Puerperium  mit  Scharlach 
und  die  sogenannte,"  "  Scarlatina  puerperalis,"  "  Arch.  f.  Gynaek.,"  Bd.  ix,  Heft  2. 
39 


610 


DISEASES  OF  CHILDBED. 


matter  of  ordinary  experience  that  the  retention  of  a  small  bit  of  the 
membranes  within  the  uterus  will  produce  fetid  lochia,  and,  as  the 
result  of  infection,  a  febrile  condition,  which,  as  a  rule,  subsides  with 
the  expulsion  of  the  offending  body  and  the  use  of  disinfectant  washes. 
A  yirulent  form  of  fever  is  not  unfrequently  occasioned  by  retained 
coagula  or  placental  debris  which  have  undergone  decomposition.  I 
was  once  sent  for  to  see  a  puerperal  patient,  suffering  from  fever,  on  the 
fourth  day  following  her  confinement.  On  entering  the  room  I  found 
the  stench  intolerable  ;  turning  down  the  sheets,  I  discovered  that  the 
patient  was  lying  in  a  decomposing  mass,  and  learned  that  her  doctor  had 
forbidden,  after  the  birth  of  her  child,  the  removal  of  the  soiled  linen 
and  blankets.  The  patient  died  in  the  third  week  from  pyaemia  multiplex. 

Haussmann  *  reported  a  case  of  auto-infection  in  the  rabbit,  which 
terminated  fatally.  A  portion  of  the  membrane,  retained  in  the  left 
cornu,  led  to  diphtheritic  losses  of  substance  in  the  lower  portion  of 
the  vagina,  to  haemorrliagic  enteritis,  and  to  peritonitis.  The  same 
author  produced  death  from  septicaemia  by  injecting  into  the  gravid 
uterus  of  the  rabbit  serum  from  the  abdomen  of  a  rabbit  which  had 
died  from  infection.  The  post-mortem  examination  showed  the  mus- 
cles filled  with  granules,  and  the  peritonaeum  injected,  but  no  fibrino- 
purulent  exudation.  Injections  into  the  uterus  of  pus  from  the  ab- 
domen of  a  woman  who  had  died  from  infectious  puerperal  disease  pro- 
duced no  effect  upon  rabbits  two  weeks  gravid,  while  in  the  second  half 
of  pregnancy  premature  delivery  and  death  occurred,  in  one  case  in  one 
and  a  half,  in  another  in  two  and  a  half  days.  In  the  animal  which 
died  in  thirty-six  hours  there  was  commencing  perimetritis  and  peri- 
tonitis, wliile  in  the  one  that  died  after  the  lapse  of  sixty  hours  the  ab- 
domen was  found  to  contain  fibrine  and  pus.f  D'Espine  injected  into 
the  uterus  of  a  rabbit,  which  had  just  produced  her  young,  pus  from 
the  abdomen  of  a  woman  who  had  died  from  puerperal  disease  two 
days  before.  This  was  subsequently  followed  by  other  injections  of 
fetid  fluids  during  the  four  days  following.  On  the  twelfth  day  the 
animal  died.  The  autopsy  revealed  peritonitis,  most  marked  in  the 
pelvic  cavity,  inflammatory  alterations  in  the  vagina,  uterus,  and 
tubes,  small  abscesses  in  the  body  of  the  uterus,  softened  clots  in  the 
veins  of  the  broad  ligaments,  and  infarctions  of  the  liver.  J;  Schiiller 
found  that  subcutaneous  injections  of  septic  material  in  female  ani- 
mals, during  pregnancy,  produced  a  diphtheritic,  ulcerative  process  on 
the  uterine  surface,  which  determined  the  separation  of  the  placenta  ; 
diphtheritic  patches,  likewise,  were  found  in  the  cornuaof  the  uterus.* 

*  "  Entstehung  der  iibcrtragbaren  Krankhciten  des  Wochenbettes,"  "  Beitr.  zur  Ge- 
burtsh.  und  Gynaek.,"  Bd.  iii,  Heft  3,  p.  345.  %  ^^^'^-j  P-  394. 

f  "  Contribution    I'etude  de  la  septicemie  puerperale,"  Paris,  1878,  p.  28. 

*  "  Experimentelle  Beitriige  zum  Studium  der  scptischen  Infection,"  "  Dtscli.  Zeit- 
Hchr.  fiir  Chir.,"  Bd.  vi,  p.  141. 


PUERPERAL  FEVER. 


611 


Tims  we  find  that  in  the  human  subject,  and  in  experiments  made 
upon  animals,  septic  poisons  introduced  into  the  system  following  or 
near  delivery  produce  lesions  similar  to  those  found  in  puerperal 
fever.  As  a  further  coincidence,  we  notice  that,  as  in  puerj^eral 
fever,  the  lesions  from  direct  septic  poisoning  have  nothing  char- 
acteristic about  them,  producing  in  one  case  pyaemia,  in  another  par- 
tial peritonitis,  in  another  general  peritonitis,  in  another  diphtheritis, 
while  in  others  the  lesions  are  comparatively  trivial — these  differ- 
ences being  due  to  differences  in  conditions  which  are  but  imperfect- 
ly understood. 

Samuel,  in  speaking  of  immunities  from  and  dispositions  to  septic 
poisoning,  says  :  The  statistical  frequency  of  septic  puerperal  dis- 
eases is  due  to  the  length  of  the  parturient  canal,  to  the  fact  that 
through  this  long  passage  there  must  pass  all  the  pathological  and 
physiological  excretions,  and  to  the  soiling  of  these  parts  with  fingers, 
instruments,  and  secretions  which  have  become  the  bearers  of  sep- 
sis." *  He  found,  on  the  other  hand,  that  it  was  extremely  difficult 
to  produce  a  progressive  ichorous  condition  by  daily  painting  an  open 
stump  with  a  septic  fluid,  f  though  the  same  was  readily  obtained 
when  an  infinitesimal  quantity  of  septic  fluid  was  injected  underneath 
a  fascia. 

Until  very  recently  the  whole  subject  of  septicaemia  has  been  in  a 
state  of  wellnigh  hopeless  confusion.  From  Gaspard  and  Panum, 
through  a  long  list  of  experimenters,  hardly  any  two  have  arrived  at 
precisely  similar  results.  Something  like  an  approach  to  order  has, 
however,  been  effected  since  it  has  begun  to  be  understood  that  the 
effects  produced  by  septic  fluids  vary  with  the  quality  of  the  poison 
and  the  method  of  experimentation,  and  that,  to  obtain  identity  in  the 
result,  there  must  be  identity  in  all  the  conditions.  Thus,  Samuel  has 
shown  that  the  same  organic  substance  produces  different  effects  at  dif- 
ferent stages  of  decomposition  ;  again,  that  the  enteritis  which  is  com- 
monly quoted  as  characteristic  of  septic  poisoning  occurs,  as  a  rule,  in 
animals  when  the  septic  fluid  is  injected  directly  into  the  blood,  and 
is  rare  when  it  finds  its  way  into  the  circulation  through  the  lymphat- 
ics, as  is  the  case  usually  in  clinical  experiences.  J;  There  is  one  ex- 
perimental point  of  extreme  practical  importance,  too,  in  connection 
with  puerperal  septicaemia,  viz.,  that,  if  the  injection  of  a  septic  fluid 
be  made  directly  into  a  vessel,  toxic  effects  speedily  follow,  but  are 
transitory,  unless  the  amount  of  the  fluid  be  large,  or  its  virulence  ex- 
ceptional, or  the  animal  very  young ;  *  whereas  very  small  amounts 
injected  subcutaneously,  by  developing  rapidly  spreading  phlegmonous 

*  "  Ueber  die  Wirkung  des  Faulniss  process  auf  den  lebenden  Organismus,"  "  Arch, 
f.  exp.  Pathol.,"  Bd.  i,  p.  343.  f  Loc.  cit.,  p.  339.  %  Loc.  cii.,  p.  349. 

*  Traube  und  Gscheidlen,  "  Versuche  uber  Faulniss  und  den  Widerstand  des  leben- 
den Organismus,"  "  Schles.  Gcs.  f.  vaterlandische  Cultur,"  February  13,  18'74. 


612 


DISEASES  OF  CHILDBED. 


inflammation,  resembling  malignant  erysipelas  in  man,  are  capable, 
after  a  period  of  incubation,  of  producing  fatal  results  ;  or  they  may, 
if  injected  into  a  shut  cavity  or  underneath  a  fascia,  lead  to  the  devel- 
opment of  an  inflammation  of  an  ichorous  character.  In  other  words, 
the  eliminating  organs  suffice,  under  ordinary  conditions,  to  remove 
from  the  blood  the  same  amount  of  septic  fluid  which  would  prove 
fatal  if  injected  into  the  tissues.*  To  produce  similar  results,  the  in- 
jections into  the  blood  need  to  be  repeated  at  intervals.  This  expe- 
rience leads  us  to  the  conclusion  that,  in  the  tissues,  septic  poison 
possesses  the  capacity  of  self-multiplication,  and  that,  in  the  local 
inflammation  set  up,  a  reservoir  is  formed  from  which  poison  is  con- 
tinuously poured  into  the  circulation. 

This  capacity  of  self-multiplication,  which  septic  fluids  possess,  has 
recently  been  found  to  be  coincident  with  the  presence  of  certain  or- 
ganic bodies,  termed  variously  micrococci,  microspores,  or  sometimes, 
less  specifically,  bacteria.  All  carefully  made  experiments  serve  to 
show  that,  if  a  septic  fluid  be  deprived  of  these  organic  bodies  by  boil- 
ing or  filtration,  while  it  continues  capable  of  producing  inflamma- 
tion, the  inflammation  is  usually  of  diminished  intensity,  and  remains 
local  in  its  character  ;  f  whereas  the  microspores,  retained  upon  the 
filter,  possess  all  the  virulent  properties  of  the  original  fluid.  J;  This 
does  not  alone  necessarily  prove  that  the  virus  resides  in  the  micro- 
spores, for  it  does  not  exclude  the  possibility  that  both  the  virus  and 
the  microspores  remain  upon  the  filter. 

So  far,  attempts  at  isolating  the  microspores  and  cultivating  them 
separately,  in  vehicles  composed  of  water  holding  in  solution  certain 
inorganic  constituents  necessary  for  their  healthy  nutrition,  have  been 
only  partially  successful  in  proving  them  to  be  the  sole  source  of  infec- 
tion. Some  experiments  of  Tiegel,  Klebs,  and  Doleris  *  were  attended 
with  positive  results,  but  Hiller  arrived  at  different  conclusions.  He 
found  that  bacteria  washed  in  pure  water  were  innocuous.  ||  But  pure 
water  had  long  before  been  proved  by  observers  to  be  inimical  to  the 
well-being  of  the  organisms  in  question.  Schiiller  says  that  Killer's 
experiments  prove  apparently  that,  while  a  putrid  fluid  may  be  in  the 
highest  degree  poisonous,  its  component  parts,  viz.,  either  the  fluid  or 

*  In  some  instances,  in  which  absorption  from  the  tissues  is  very  rapid,  the  effects  of 
subcutaneous  injections  may  be  similar  to  those  produced  by  injections  made  directly  into 
the  circulation,  and  the  local  lesion  be  insignificant. 

f  In  filtration  through  porous  earthenware  cylinders,  the  filtrate  possesses  no  phlogo- 
genic  properties. 

:j:  Tiegel,  "  Corrcspondenzblatt  f.  Schweizer  Aertze,"  18*71,  p.  1275;  Klebs,  "Arch, 
f.  exp.  Pathol,  und  Pharmakol.,"  Bd.  i,  Heft  1,  p.  35. 

*  Klebs,  *'  Beitrage  zur  Kenntniss  der  pathogenen  Schistomycetin,"  "  Arch.  f.  exp. 
Pathol,  und  Pharmakol.,"  Bd.  iv.  Heft  8,  pp.  241  et  seq.  ;  Tiegel,  loc.  cit. 

II  "  Exp.  Beitrage  zur  Lehre  von  der  organisirte  Natur  der  Contagion  und  von  der 
Faulniss,"  "  Arch.  f.  klin.  Oliir.,"  Bd.  xvii,  Heft  4,  pp.  669  et  seq. 


PUERPERAL  FEVER. 


613 


614 


DISEASES  OF  CHILDBED. 


the  bacteria  singly,  are  neither  deadly  nor  poisonous.*  The  fact  is, 
that  all  isolation  experiments  are  subject  to  what  seems  an  unavoidable 
source  of  error.  As  Davaine  noted,  early  in  his  obseryations,  the 
physiological  action  of  bacteria  is  very  dependent  on  the  constitution 
of  the  medium  in  which  they  are  developed,  which  is  in  entire  har- 
mony with  what  is  known  of  organisms  much  higher  in  the  scale. 
"Many  plants,"  says  Burdon-Sanderson,t  "containing  active  prin- 
ciples become  inert  when  transplanted  from  an  appropriate  soil.'' 
Buchholtz,  in  a  series  of  ex^^eriments  designed  to  test  the  influence  of 
antiseptics  upon  the  vitality  of  bacteria,  found  not  only  a  difference 
between  those  taken  directly  from  the  infusion  and  those  cultivated 
in  artificial  fluids,  but  between  bacteria  derived  from  the  same  source 
and  cultivated  in  modifications  of  the  nutrient  medium.  J  Under  these 
circumstances,  all  evidence  of  a  positive  character  is  to  be  regarded  as 
of  more  value  than  that  which  is  purely  negative. 

It  is,  however,  from  the  constant  presence  of  the  round  bacteria  in 
infected  wounds,  and  their  distribution  through  the  tissues,  that  the 
argument  in  favor  of  connecting  septic  symptoms  with  the  bacteria 
has  been  mainly  deduced.  Here  the  ground  is  sufficiently  solid,  and, 
judged  by  ordinary  laws  of  scientific  evidence,  the  pathological  im- 
portance of  the  microspores  may  be  regarded  as  established.  To  be 
sure,  we  find  them  in  tongue-scrapings  of  healthy  individuals,  but 
tongue-scrapings  are  poisonous  if  injected  into  the  tissues.  That  they 
do  not  ordinarily  prove  so  in  the  mouth  is  no  more  singular  than  that 
woorara  can  be  swallowed  with  impunity.  Tiegel  has  endeavored  to 
show  that  the  round  bacteria  are  found  normally  in  the  internal  organs 
of  the  body.*  If  his  experiments  should,  in  fact,  stand  the  test  of 
criticism,  they  would  only  show  that  a  few  bacteria  may  be  found  in 
health  in  the  liver  and  in  the  pancreas,  but  never  in  anything  like  the 
same  numbers  or  the  same  general  distribution,  nor  with  the  same 
characteristic  groupings,  that  have  been  proved  for  a  number  of  infec- 
tious diseases.  ||  It  is  stated  that  they  are  sometimes  absent  from  the 
blood  taken  during  life  in  septic  diseases.  As,  however,  their  constant 
presence  has  been  confirmed  in  the  vessels  and  glomeruli  of  the  kid- 
ney, it  is  fair  to  assume  that  they  are  filtered  out  by  those  organs  when 
the  conditions  favorable  to  their  development  do  not  exist  in  the  blood. 
Again,  it  is  an  open  question,  which  awaits  confirmation,  whether  it  be 
not  true,  as  Hueter  claims,  that  the  microspores  do  not  disappear,  but 

*  "  Exp.  Beitriige  zum  Studium  der  septischen  Infection,"  "  Dtscli.  Ztschr.  f.  Chir.," 
Bd.  vi,  p.  162. 

f  Lectures  on  "  The  Relations  of  Bacteria  to  Disease,"  "  Brit.  Med.  Jour.,"  March  21, 
1875  ;  see,  also,  Klebs,  *'  Beitrage  zur  Kenntniss  der  pathogenen  Schistomycetin," 
"  Arch.  f.  cxp.  Pathol,  und  Pharmakol.,"  Bd.  iii,  p.  321. 

X  Antiseptica  und  Bacterien,"  "Arch.  f.  exp.  Pathol,  und  Pharmakol.,"  Bd.  iv,  Heftc 
1  und  2.  #  "  Arch.  f.  path.  Anat.  u.  Physiol,  u.  f.  klin.  Med.,"  Bd.  Ix,  p.  453. 

I  Klebs,  "  Arch.  f.  exp.  Pathol,  und  Pharmakol,"  Bd.  iii,  p.  319. 


PUERPERAL  FEVER. 


615 


are  taken  up  by  the  blood-globules,  rendering  the  latter  adhesive^  and 
predisposing  the  blood  to  the  stases  characteristic  of  inflammation.* 
Zahn  has  shown  that  the  inflammation  in  the  mesentery  of  the  frog, 
in  the  Cohnheim  experiment,  does  not  take  place  if  the  air  is  first  fil- 
tered through  diluted  carbolic  acid.f 

As  to  the  exact  manner  in  which  these  minute  bodies  exercise  their 
pernicious  influence,  whether  they  operate  mechanically,  or  whether 
they  produce  a  virus  in  the  process  of  nutritive  activity,  or  whether, 
as  is  probable,  both  suppositions  are  correct,  we  may  safely  leave  as 
questions  to  be  decided  by  subsequent  investigations.  It  is  enough 
for  us  to  note  that  the  connection  between  sepsis  and  the  round  bac- 
teria is  intimate  and  vital.  Panum,  who  is  often  quoted  as  opposed 
to  what  is  known  as  the  bacteria  theory,  admits  as  probable  that  the 
microsporon  septicum  is  inoculable,  appears  in  the  blood  during  life, 
multiplies  in  the  tissues,  and,  in  part  by  production  of  a  special  poison, 
perhaps,  and  in  part  by  mechanically  irritating  the  tissues,  excites  in- 
flammation, suppuration,  and  fever.  J  Bergmann,  who  once  thought 
that  he  had  found  the  secret  of  sepsis  in  a  crystallizable  substance 
derivable  from  putrid  fluids,  which  he  termed  sepsin,*  now  squarely 
accepts  the  modern  doctrine.  Virchow  has  so  far  given  in  his  adhe- 
sion to  the  new  school  as  to  say  :  Especially  in  this  connection  are 
to  be  mentioned  the  diphtheritic  process  and  the  erysipelatous,  espe- 
cially erysipelas  malignum.  The  granular  deposit  in  diphtheritically 
affected  tissues,  of  which  I  formerly  spoke,  has  more  and  more  proved 
to  be  of  a  parasitic  character.  What  we  formerly  regarded  as  simple, 
organic  granules,  as  infiltration,  or  exudation,  has  since  proved  to  be 
a  dense  aggregation  of  micro-organisms  which  penetrate  into  the  tis- 
sues and  cells  to  compass  their  destruction."!  Even  Billroth,  who 
contends  that  what  he  terms  a  zymoid  ferment  is  the  first  thing  devel- 
oped in  the  line  of  causation,  and  that  the  bacteria  are  a  sort  of  epi- 
phenomenon,  concedes  that  the  organisms,  by  their  migrations,  may 
become  the  carriers  of  the  virus  into  the  interstices  of  the  tissues.  I 
mention  the  less  willing  witnesses  to  the  importance  of  bacteria  in  dis- 
ease :  I  need  not  recapitulate  the  names  of  a  host  of  active  advocates 
of  the  germ  theory. 

*  "  Allgemeine  Chirurgic,"  Cap.  xvii,  "Dcr  ficbcrhafte  Process."  So,  too,  Schiiller, 
loc.  cit,  pp.  168  et  scq.  Birch-Hirschfeld  likewise  found  bacteria  in  the  white  globules  of 
pyfemia,  Schmidt's  "  Jahrbiicher,"  Bd.  166,  No.  5,  p.  187. 

f  "  Arbeiten  an  der  Berner  pathol.  Institut.,"  1871. 

X  "  Das  putride  Gift,  die  Bacterien,  die  putride  Infection  und  Intoxication,  und  die 
Septicaemie,"  "  Arch.  f.  path.  Anat.  u.  Physiol,  u,  f.  klin.  Med.,"  Bd.  Ix,  p.  3i8. 

*  I  have  not  been  able  to  obtain  access  to  Bergmann's  original  paper,  but  make  this 
statement  on  the  authority  of  Ilueter,  "  Allgemeine  Chirurgie,"  p.  543. 

II  "Die  Fortschritte  der  Krieg's  ITeilkunde,"  Berlin,  1874. 

^  "  Untersuchungen  iibcr  die  Vegetaliensformen  von  Coccobacteria  septica,"  Berlin, 
1874,  p.  200. 


616 


DISEASES  OF  CHILDBED. 


I  have  been  thus  explicit  regarding  the  evidence  concerning  bacteria 
in  septic  diseases,  because  it  places  the  question  of  the  infectious  group 
of  puerperal  fever-cases  in  the  following  position  :  Experiences  oc- 
curring clinically,  as  well  as  those  produced  upon  animals,  teach  us 
that  certain  lesions  and  symptoms,  similar  to  those  we  are  accustomed 
to  regard  as  characteristic  of  puerperal  fever,  result  from  septic  poison- 
ing. In  a  large  class  of  cases,  however,  the  connection  between  child- 
bed-fever and  sepsis  has  been  deduced  rather  from  analogy  than  direct 
proof.  For  those  who  chose  to  regard  such  as  due  to  a  specific  poison 
peculiar  to  the  puerperal  state,  there  was  really  no  objection.  If,  how- 
ever, round  bacteria  are  characteristic  of  septic  poisoning,  the  ques- 
tion presents  itself  in  a  different  light,  and  we  have  to  inquire  whether, 
in  the  less  obvious  cases,  bacteria  are  present  in  puerperal  fever  in  the 
proportions  and  groupings  that  we  find  them  in  other  diseases  due  to 
putrid  infection.  Now,  it  is  precisely  proof  of  this  nature  that  has 
recently  been  abundantly  rendered. 

Waldeyer,*  Orth,f  Heiberg,;];  and  Von  Eecklinghausen,  found  the 
tissues  and  lymphatics  of  the  parametria  filled  with  pus-like  masses, 
which  consisted,  in  addition  to  pus-cells,  chiefly  of  bacteria.  Bacteria 
swarmed  in  the  fluid  of  the  peritoneal  cavity.  In  one  case  examined 
by  Waldeyer,  six  hours  after  death,  while  the  body  was  still  warm,  the 
peritoneal  exudation  was  like  an  emulsion,  and  furnished  an  abundant 
deposit  which  consisted  almost  entirely  of  bacteria.  Orth  injected  ten 
minims  of  peritoneal  fluid  from  a  woman  dead  of  puerperal  fever  into 
the  abdomen  of  a  rabbit.  As  the  animal  was  dying  he  broke  up  the 
medulla  oblongata,  and  found  in  the  peritoneal  fluid  enormous  quan- 
tities of  these  organisms.  In  puerperal  fever  round  bacteria  have  been 
likewise  found,  though  in  less  quantities,  in  the  lymphatics  of  the  dia- 
phragm and  in  the  fluids  of  the  pleura,  the  pericardium,  and  the 
ventricles  of  the  brain.  In  post-mortem  examinations  of  fresh  sub- 
jects, the  serous  fluids,  withdrawn  under  proper  precautions,  do  not 
contain  round  bacteria  except  in  cases  of  septic  infection.*  Orth  found 
in  the  purulent  contents  of  the  vessels  of  the  funis,  in  children  who 
died  of  sepsis,  precisely  the  same  formations  as  existed  in  the  exuda- 
tions of  the  mother. 

The  presence  of  these  germs  in  puerperal  fever  serves  not  only  to  fix 
cases  hitherto  considered  doubtful  in  the  category  of  septic  diseases, 
but  it  affords  the  best  explanation  of  the  protean  phenomena  of  puer- 
peral fever  itself.    Steurer,  formerly  interne  at  the  Bellevue  Hospital, 

*  "  Ucbcr  das  Vorkomraen  von  Bacterien  bei  der  diphtherilischen  Form  des  Puerpe- 
ral-fiebers,"  "  Arch,  f .  Gynalc,"  Bd.  iii,  p.  293. 

f  "  Untorsuchungen  iiber  Puerperal-fiebcr,"  "  Arch.  f.  path.  Anat.  u,  Physiol,  u.  f. 
klin.  Med.,"  Bd.  Iviii,  p.  43'7. 

X  "Die  puerpcralen  und  pyaDmischen  Proccsse,"  Lcipsic,  1873. 

*  Klebs,  "  Beitriige  zur  Kenntniss  der  pathogcncn  Sciiistoniycetin,"  "  Arch.  f.  exp. 
Pathol,  und  Pharmakol.,"  Bd.  iv,  pp.  441  et  seq. 


PUERPERAL  FEVER. 


617 


where  he  witnessed  the  epidemic  which  prevailed  in  that  institution  in 
the  year  1874,  afterward  made,  under  the  guidance  of  Professor  von 
Kecklinghausen,  a  special  investigation  of  the  pathological  changes  in 
a  similar  epidemic  which  occurred  in  Strasbourg.  From  a  written 
communication  received  by  me  from  Dr.  Steurer,  many  of  the  follow- 
ing facts  concerning  the  pathogeny  of  the  disease  have  been  derived. 
These  facts,  I  may  add,  are  fully  supported  by  the  investigations  of 
others,  and  form  a  most  valuable  contribution  to  our  knowledge  of 
puerperal  fever. 

Steurer's  cases  all  presented  diphtheritic  patches  about  the  vulva, 
or  upon  the  mucous  membrane  of  the  vagina  and  uterus.  These 
patches  were  always  associated  with  a  loss  of  substance,  and  were  com- 
posed of  disintegrated  fibrine,  white  and  red  blood-corpuscles,  and  colo- 
nies of  round  bacteria  in  great  abundance.  From  the  patches,  the 
bacteria  could  be  traced  between  the  muscular  fibers,  and  deep  down 
into  the  canalicular  spaces  of  the  connective  tissue,  where  their  pres- 
ence gave  rise  to  cellulitis.  From  the  canalicular  spaces  they  entered 
the  lymphatics,  with  resulting  lymphangitis.  In  many  cases  the  lym- 
phatics could  be  traced  along  the  broad  ligaments  to  the  ovaries  (puer- 
peral oophoritis)  and  into  the  subperitoneal  tissue  of  the  lumbar  region. 
By  perforation  of  the  walls  of  the  lymphatics  which  directly  underlie 
the  peritonasum,  they  made  their  way  into  the  peritoneal  cavity  and 
excited  pyaemic  peritonitis,  an  affection  which  differs  from  traumatic 
peritonitis,  and  for  which  the  claim  has  been  set  up  that  it  is  peculiar 
to  puerperal  fever.  The  wide  stomata  upon  the  abdominal  surface  of 
the  diaphragm  allowed  the  facile  entrance  of  the  organisms  into  its 
lymphatics.  Waldeyer  found  in  diaphragmitis  the  lymphatics  of  the 
diaphragm  tilled  with  bacteria.  And  thus  following  the  lymphatic 
system,  if  we  only  admit  that  the  round  bacteria  are  the  carriers  of 
sepsis,  a  fact  which  hardly  admits  of  dispute,  the  frequency,  in  severe 
types  of  puerperal  fever,  of  inflammations  of  the  serous  membranes — 
of  the  peritonaeum,  the  pleurae,  the  pericardium,  and  the  joints — finds 
an  easy  explanation.  We  can  understand,  too,  how  it  is  not  always 
altogether  accident  which  determines  in  different  cases  the  precise  se- 
rous membranes  which  are  affected. 

Thexluctus  thoracicus  is  the  principal  channel  through  which  the 
poison  enters  the  blood.  Bacteria  are  difficult  to  find  in  the  blood 
during  life.  A  few  hours  after  death  they  swarm  in  that  fluid.  Pos- 
sibly the  rapidity  of  the  blood-currents  during  life  does  not  favor  the 
multiplication  of  bacteria.  That  they,  however,  enter  the  general  cir- 
culation during  life,  is  incontestable.  Steurer  writes,  *^As  the  kid- 
neys are  the  great  filters  of  the  human  system,  I  never  neglected  to 
examine  them,  and  almost  invariably  found  the  glomeruli  and  arterioli 
filled  with  micrococci  (round  bacteria)."  This  is  in  correspondence 
with  what  occurs  in  other  septic  diseases,  and  accounts  for  the  albu- 


618 


DISEASES  OF  CHILDBED. 


minuria  and  interstitial  nephritis  which  often  supervene  in  the  ad- 
vanced stages.  We  have  seen  ah^eady  that,  in  consequence  of  septic 
poisoning,  the  white  blood-globules  have  a  tendency  to  adhere  to  the 
walls  of  the  vessels.  This  leads  to  stases  in  the  capillaries,  to  conges- 
tion of  the  deep-seated  organs,  and  to  an  increase  of  blood  in  the  large 
veins  of  the  trunk.  Finally,  death  takes  place  from  apnoea,  partly 
from  the  inability  of  the  blood-corpuscles  to  carry  oxygen  to  the  tis- 
sues, and  partly  from  paralysis  of  the  respiratory  nerve-centers.* 
Sometimes  the  bacteria  pass  directly  into  the  veins,  where  they  give 
rise  to  phlebitis.  Professor  von  Eecklinghausen  recognizes  three  ways 
in  which  this  may  take  place  :  1.  Through  a  thrombus  (and  here  let 
me  call  to  mind  that  it  is  very  common  in  uterine  phlebitis  to  find  the 
uterus  large,  and  the  vessels  at  the  placental  site  filled  with  soft 
thrombi)  ;  2.  Through  direct  perforation  of  the  venous  walls ;  3.  By 
being  taken  up  by  white  corpuscles  and  by  them  conveyed  into  the 
vessels  in  the  manner  described  by  Cohnheim. 

When  the  bacteria  enter  directly  into  the  circulation,  they  some- 
times, in  passing  through  the  heart,  adhere  to  the  endocardium  and 
the  valves,  causing  exudation,  ulceration,  and  decomposition,  and  thus 
give  rise  to  the  so-called  endocarditis  ulcerosa  puerperalis.  f  In  the 
cases  studied  by  Waldeyer  and  Steurer  there  were  diphtheritic  patches, 
serving  as  the  starting-points  of  the  puerperal  processes.  Whether 
these  so-called  diphtheritic  patches  are  identical  with  those  which 
appear  in  the  throat,  is  an  open  question.  Morphologically,  they  are 
so,  but  in  hospitals  epidemics  of  puerperal  diphtheritis  are  not  associ- 
ated with  throat  diphtheritis. 

To  avoid  misapprehension,  let  me  distinctly  state  that  diphtheritic 
patches  are  not  necessary  to  the  infectious  form  of  puerperal  fever. 
They  indicate  an  unwholesome  atmospheric  condition,  and  are  some- 
what rare  outside  of  public  institutions.  Orth  and  Heiberg  noticed  the 
same  general  post-mortem  changes  in  those  cases  in  which  the  patches 
were  absent  as  in  those  in  which  they  were  present.  My  own  obser- 
vations show  that  they  are  rarely  developed  in  the  early  stages  of  a 
hospital  epidemic  of  puerperal  fever,  nor  are  they  to  be  found  in  all 
cases  when  such  an  epidemic  is  at  its  height.  In  some  of  the  lying-in 
hospitals  in  Europe  puerperal  diphtheritis  appears,  however,  to  be 
endemic. 

The  question  as  to  the  extent  to  which  erysipelas  and  puerperal 
fever  are  cognate  diseases  is  in  a  fair  way  to  be  solved  by  recent  inves- 
tigation. Orth  took  the  contents  of  a  vesicle  from  an  erysipelatous 
patient,  which  contained  bacteria  in  great  abundance,  and  employed 

*  Vide  ScHULLER,  *'  Exp.  Beitrage  zum  Studium  dcr  scptischen  Infection,"  "  Dtsche. 
Ztschr.  f.  Chir.,"  Bd.  vi,  Hcfte  1  u.  2,  pp.  149  et  seq. 

\  Heiberg  ("Die  puerperalen  und  pyaemischen  Processe,"  Leipsic,  1873,  pp.  22,  34) 
gives  references  to  cases  reported  by  Wicge  and  Eberth. 


PUERPERAL  FEVER. 


619 


the  same  for  injections  under  the  skin  of  rabbits.  In  this  way  he 
succeeded  in  producing  in  these  animals  a  species  of  erysipelas  malig- 
num.  In  the  subcutaneous  cedema  and  affected  portions  of  the  skin 
he  found  enormous  masses  of  bacteria,  so  far  exceeding  in  quantity 
the  amount  introduced  as  to  prove  an  abundant  new  production.* 
Samuel  produced  similar  results  by  the  injection  of  ordinary  putrid 
Huids  containing  round  bacteria.  An  affection  resembling  simple 
erysipelas  he  obtained  most  frequently  by  the  application  of  fluid  to  a 
Yv^ound  torn  open  after  the  second  or  third  day.  f  Lukowski  found 
that  erysipelas  could  be  produced  by  fluid  containing  micrococci,  even 
when  putrefaction  did  not  exist.  The  contents  of  erysipelatous  vesicles 
containing  no  micrococci  excited  no  morbid  manifestations.  Where 
the  erysipelatous  process  was  fresh  and  progressing,  micrococci  were 
found  in  great  abundance  in  the  lymphatics  and  canalicular  spaces. 
Where  ttlie  process  was  retrogressive,  there  were  no  micrococci  to  be 
found,  even  in  cases  in  which  inflammation  existed  to  an  intense 
degree.  I    Virchow's  testimony  we  have  already  given. 

Thus  we  find  in  surgical  fever,  in  puerperal  fever,  in  diphtheria, 
and  in  erysipelas,  the  presence  of  a  common  element  which  links  them 
together,  and  which  establishes  the  relationship  which  has  long  been 
recognized  as  existing  between  these  various  processes.  Experiments, 
made  by  competent  men  with  care  and  intelligence,  serve  continually 
to  increase  the  probability  that  the  bacteria  are  no  chance  products, 
but  that  they  have  a  vital  connection  with  the  diseases  designated. 
Whether  these  organisms  are  identical  in  the  different  infectious  dis- 
eases in  which  they  have  been  recognized,  is  another  question.  Billroth 
complains  of  the  monotonous  appearance  of  always  the  same  forms.* 
When  we  bear  in  mind,  however,  that  our  best  instruments  fail  to 
enable  us  to  distinguish  the  ovum  which  is  to  produce  a  mouse  from 
one  that  will  produce  a  tiger,  though  the  ovum  is  at  least  one  hundred 
times  larger  than  the  micrococcus,  the  argument  loses  something  of 
its  value.  Whether  identical  or  not,  they  all  possess  the  common 
property  of  penetrating  the  tissues,  under  favorable  conditions,  of 
multiplying,  and  of  producing,  by  their  migrations,  local  inflamma- 
tions and  general  infection. 

I  can  not  refrain,  in  conclusion,  from  quoting  entire  the  following 
statement  of  Panum,  which  appears  to  reconcile  certain  differences  in 
the  definitions  of  the  term  septicaemia  by  different  authors  : 

"  The  putrid  poison  may,  during  life,  enter  the  blood  with  or  without  bac- 
teria, especially  from  wounds,  and  occasion  all  the  symptoms  of  septic  poisoning, 

*  "  Untersuchungen  iiber  Erysipel,"  "  Arch,  fiir  exp.  Pathol,  und  Pharmakol.,"  Bd. 
i,  p.  81. 

f  "Arch,  fiir  cxp.  Pathol,  und  Pharmakol.,"  Bd.  i,  pp.  335  et  scq. 
\  **  Untersuchungen  iiber  Erysipel,"  "  Archiv.  f.  path.  Anat.  u.  Physiol,  u.  f.  klin. 
Med.,"  Bd.  Ix,  p.  430.  *  "  Untersuchungen  iiber  die  Coccobacteria  septica,"  p.  3. 


620 


DISEASES  OF  CHILDBED. 


whereas,  however,  the  'bacterium  termo  does  not  appear  to  occur  in  the  blood 
during  life.  This  simple  putrid  infection  does  not  appear  to  he  inoculable. 
Another,  as  it  appears,  distinct,  specific,  pathogenic  fungus,  the  microsporon 
septicum  of  Klebs,  developed  especially  in  pus  (and  blood  ?),  perhaps  under  the 
predisposing  influence  of  the  putrid  poison,  when  the  air  (as  in  overcrowded 
hospitals)  contains  the  latter,  or  when  it  is  transferred  by  inoculation,  seems,  on 
the  other  hand,  during  life  to  increase  in  the  blood  and  tissues,  and  in  part,  per- 
haps, by  production  of  a  special  poison,  in  part,  perhaps,  in  a  more  mechanical 
way,  by  penetration,  and,  under  circumstances,  by  its  irritative  action  on  the 
tissues,  excites  inflammation,  purulence,  and  fever."* 

Clinical  History. — As  in  other  infectious  diseases,  there  is,  from  the 
time  of  the  entry  of  the  poison  into  the  system  up  to  the  outbreak  of 
fever,  a  distinct  period  of  incubation.  The  first  febrile  symptoms 
usually  occur  within  three  days  of  the  birth  of  the  child.  An  at- 
tack coming  on  a  few  hours  after  childbirth  is  indicative  of  infection 
during  or  previous  to  labor.  The  third  day  is  the  one  upon  which 
ordinarily  the  beginning  of  the  fever  is  to  be  anticipated.  After  the 
fifth  day  an  attack  is  rare,  and  at  the  end  of  a  week  patients  may  be 
regarded  as  having  reached  the  point  of  safety.  Apparent  exceptions 
to  this  rule  are  probably  referable  to  cases  of  mild  parametritis,  in 
which  the  initial  fever  and  the  pain  were  insufficient  to  attract  atten- 
tion to  the  existence  of  local  inflammation. 

The  symptoms  of  puerperal  fever  .vary  with  the  character  of  the 
local  affections  and  with  the  extent  to  which  the  general  system 
participates  in  the  disturbed  action.  The  different  groups  of  puer- 
peral processes  possess  the  following  pathognomonic  symptoms,  viz., 
increased  temperature,  enlargement  of  the  spleen,  disturbed  involu- 
tion and  sensitiveness  of  the  uterus  upon  pressure  (Braun). 

In  most  cases  the  fever  is  ushered  in  by  chilly  sensations,  or  by  a 
well-defined  chill.  This  symptom,  however,  does  not  possess  much 
prognostic  importance.  A  chill  is  significant  of  a  sudden  change 
between  the  temperature  of  the  skin  and  that  of  the  surrounding 
medium.  It  may,  therefore,  be  absent  in  pernicious  forms  of  fever, 
provided  only  that  the  temperature  changes  are  inaugurated  slowly, 
whereas  it  may  follow  a  trifling  increase  of  the  body-heat  if,  as  some- 
times happens  in  sleep,  the  moist  skin  is  exposed  to  cool  currents  of 
air.    Eepeated  chills  indicate  phlebitis  and  pyemia. 

In  order  to  grasp  tlie  many  symptoms  of  puerperal  fever,  it  is  neces- 
sary to  keep  separately  in  mind  the  clinical  features  of  each  of  the 
local  processes,  although  in  fact  the  latter  rarely  occur  singly,  but  to 
a  greater  or  less  extent  in  combination  with  others. 

The  Symptoms  of  Endometritis  and  Endocolpitis. — The  uncom- 

*  *'  Das  putride  Gift,"  etc.,  "  Archiv.  f.  path.  Anat.  u.  Physiol,  u.  f .  Idin,  Med.,"  Bd. 
Ix,  p.  34!).  I  have  translated  literally.  The  meaning  of  the  sentences,  in  spite  of  the 
involved  construction,  is  sufficiently  clear. 


PUERPERAL  FEVER. 


621 


plicated  catarrhal  inflammation  of  the  uterus  and  vagina  is  the  most 
frequent  and  the  mildest  of  the  diseases  of  childbed.  In  endome- 
tritis the  uterus  is  large,  flabby,  and  sensitive  upon  pressure  ;  the  after- 
pains  are  often  unusually  severe,  involution  is  retarded,  and  the 
lochia  become  fetid,  remain  sanguinolent  for  a  longer  period  than 
usual,  and  at  the  outset  may  be  temporarily  suspended.  Sometimes 
the  large  intestine  is  distended  with  flatus.  In  endocolpitis  the 
vaginal  discharge  is  thin  and  purulent,  the  patient  experiences  pain 
and  burning  in  the  acts  of  defecation  and  urination,  and,  where  the 
wounds  of  the  vulva  and  vagina  assume  an  ulcerative  character,  there 
is  often  found  at  the  same  time  inflammatory  oedema  of  the  labia. 

The  fever  in  these  cases  is  ushered  in  frequently  but  not  always 
by  chilly  feelings,  and  the  temperature  reaches  its  height  usually  upon 
the  evening  of  the  third  or  fourth  day,  is  remittent,  almost  intermit- 
tent in  character,  and  rarely  exceeds  102°  to  103°.  In  mild  forms  the 
occurrence  of  the  fever  is  often  overlooked,  or  is  referred  to  disturb- 
ance produced  by  the  secretion  of  the  milk.  In  severer  attacks  the 
febrile  symptoms  may  continue  from  three  to  seven  days.  At  the  end 
of  a  week  the  swelling  of  the  labia  subsides,  the  discharge  becomes 
thick,  and  ulcers,  if  present,  begin  to  assume  a  healthy  granulating 
appearance. 

In  diphtheritic  ulcerations,  and  in  endometritis  due  to  decomposing 
remains  of  the  ovum,  the  local  condition  is  often  complicated  by  the 
invasion  of  the  neighboring  tissues. 

Parametritis  and  Perimetritis  (Pelvic  peritonitis).* — The  symptoms 
of  these  two  affections,  as  would  be  naturally  expected  from  the  prox- 
imity of  the  peritonaeum  to  the  pelvic  connective  tissue,  for  the  most 
part  overlap.  It  must  be  very  rare  for  one  form  to  occur  entirely  in- 
dependent of  the  other.  For  this  reason  it  will  be  found  convenient 
to  consider  first  the  symptoms  common  to  both  morbid  processes,  and 
subsequently  to  direct  attention  to  what  are  believed  to  be  points  of 
distinction  between  them. 

During  the  period  of  incubation  there  are  usually  no  prodromic 
symptoms.  Elevations  of  temperature  in  the  course  of  the  first  twelve 
hours  following  labor  are  equally  frequent  under  perfectly  normal  con- 
ditions. Suspicious  symptoms  are  disturbed  sleep,  excessively  painful 
after-pains,  and  a  pulse  of  80  to  90. 

The  beginning  of  the  fever  occurs  in  ninety  per  cent,  within  the 
first  four  days  of  childbed  ;  most  frequently  upon  the  second  or  third 
day,  and  taking  place  upon  the  fourth  day  in  scarcely  twelve  to  fifteen 
per  cent,  of  the  cases.    If  five  days  have  elapsed  without  fever,  the 

*  The  following  clinical  history,  together  with  the  statistical  details,  is  borrowed  in 
great  part  from  the  description  of  Olshausen  ("  Ueber  puerperale  Parametritis  und  Peri- 
metritis," Volkmann's  "  Samml.  klin.  Vortr.,"  No.  28),  the  exactitude  of  which  I  have 
had  abundant  opportunity  to  verify. 


622 


DISEASES  OF  CHILDBED. 


X^eriod  of  danger,  with  very  rare  exceptions,  may  be  regarded  as  hav- 
ing passed. 

At  the  outset  the  fever,  especially  in  perimetritis,  is  ushered  in  by 
chilly  sensations,  or  by  an  intense  chill.  The  temperature  rises  rapid- 
ly, though  the  highest  point  is  usually  not  reached  before  the  second, 
and  in  rare  cases  not  before  the  third,  day.  In  most  cases  the  heat  in 
the  axilla  exceeds  103°,  and  may  even  mount  up  to  105°.  The  decline 
occurs  gradually,  the  fever  ending  in  seventy  per  cent,  in  the  course 
of  a  week,  in  twenty  per  cent,  in  two  weeks,  and  only  in  ten  per  cent, 
extending  beyond  that  period.  Protracted  cases  indicate  abscess 
formation. 

The  fever  does  not,  however,  always  pursue  a  regular  course.  In 
place  of  progressively  declining  until  the  termination  is  reached,  the 
high  temperature  of  the  second  day  may  be  attained  upon  one  or  more 
occasions.  The  morning  remissions  are  at  first  slight,  but  become 
marked  as  the  disease  approaches  its  close.  In  cases  of  long  duration 
the  morning  hours  are  often  free  from  fever,  a  circumstance  calculated 
to  mislead  a  physician  who  sees  his  patient  but  once  a  day.  A  pulse 
of  80  to  90  beats,  a  disturbed  sleep,  lack  of  appetite,  and  sensitiveness 
to  pressure  upon  the  sides  of  the  uterus  are,  however,  symptoms  which 
should  serve  as  a  warning  of  some  disturbing  cause,  and  should  lead 
the  physician  to  renew  his  visit  in  the  latter  part  of  the  day. 

If,  from  a  mistaken  notion  that  the  morbid  process  has  come  to 
an  end,  the  patient  is  allowed  prematurely  to  resume  her  household 
duties,  the  pains  across  the  abdomen  and  along  the  hip  and  thigh 
return,  and  an  examination  reveals  the  existence  of  exudation  in  the 
pelvic  cavity  or  upon  an  iliac  fossa. 

Errors  of  this  kind  are  most  frequent  in  cases  of  parametritis 
associated  with  slight  peritoneal  inflammation,  as  the  local  pain  is 
then  insignificant,  and  the  initial  chill,  happening  on  the  third  or 
fourth  day,  is  apt  to  be  ascribed  to  engorgement  of  the  breasts. 

Relapses  after  the  complete  disappearance  of  febrile  disturbance 
occur  in  fifteen  to  twenty  per  cent.  They  are  usually  shorter,  but 
sometimes  more  obstinate,  than  the  original  attack.  As  a  rare  excep- 
tion may  be  mentioned  cases  with  evening  remissions  and  morning 
exacerbations. 

In  circumscribed  pelvic  inflammations  the  pulse  rarely  exceeds  120 
beats  to  the  minute.  A  pulse  of  140,  of  more  than  a  half-day's 
duration,  betokens  severe  septic  complications,  and  is  therefore  of  evil 
omen.  In  some  cases  the  slow  pulse  observed  after  labor  makes  its 
influence  felt  in  the  first  day  or  two  of  the  fever,  so  that  the  curi- 
ous phenomenon  may  be  witnessed  of  a  temperature  of  104°  coin- 
ciding for  a  time  with  a  pulse  ranging  between  50  and  70  beats  to  the 
minute. 

As  regards  other  symptoms,  headache  and  sleeplessness  are  rarely 


PUERPERAL  FEVER. 


623 


absent.  Profuse  sweating  follows  the  first  febrile  attack,  and  fre- 
quently recurs  during  the  course  of  the  disease. 

Pain  is  present  at  the  onset  in  the  majority  of  cases,  and  is  then 
usually  most  violent.  The  spontaneous  pain,  which  is  due  to  the  affec- 
tion of  the  peritonaeum,  subsides  in  great  part  in  the  course  of  one  or 
two  days,  but  the  sides  of  the  uterus  remain  sensitive  to  pressure. 
In  the  rare  cases  of  pure  parametritis,  however,  this  symptom  may  be 
absent  altogether. 

The  pain,  like  that  from  the  inflammation  of  serous  membranes,  is 
of  a  lancinating  character.  Sometimes  it  is  associated  only  with  the 
contractions  of  the  uterus.  After-pains  occurring  under  unusual  cir- 
cumstances, as  in  primiparae  or  after  the  third  day,  are  to  be  regarded 
with  suspicion. 

Vomiting  occurs  occasionally,  but  is  comparatively  rare  unless  the 
peritonitis  becomes  diffused  and  spreads  to  the  region  of  the  stomach. 
The  appetite  is  lost,  and  only  returns,  as  a  rule,  with  the  departure 
of  the  fever.  The  tongue  is  coated  and  moist,  and  constipation  is 
common.  In  other  cases  there  is  diarrhoea  with  rumbling  in  the  bow- 
els, but  without  pain  or  tenesmus.  The  urinary  secretion  is  rarely 
interfered  with,  and  when  this  is  the  case  it  indicates  the  extension  of 
the  inflammation  to  the  peritonaeum  covering  the  bladder. 

Most  cases  of  perimetritis  and  parametritis  terminate  in  five  or 
ten  days,  the  fever  and  other  symptoms  gradually  subsiding.  When, 
as  may  happen  in  exceptional  instances,  the  temperature  falls  suddenly 
from  a  high  to  one  below  the  normal  level,  the  body  grows  icy  cold, 
the  pulse  becomes  small  and  irregular,  and  symptoms  of  collapse  de- 
velop. But  in  twelve  to  twenty-four  hours  the  symptoms  of  collapse 
subside,  and  the  disease  reaches  its  end  with  a  disappearance  of  the 
alarming  manifestations. 

If  the  fever  subsides  within  a  week,  exudation  is  somewhat  rare. 
Its  continuance  beyond  that  date  should  lead  to  a  careful  exploration 
of  the  pelvic  organs.  The  exudation  is  usually  demonstrable  in  the 
course  of  the  second  week  or  at  the  beginning  of  the  third  week.  It 
is  recognized,  according  to  its  location,  by  external  or  by  internal  exam- 
ination, or,  where  the  deposit  is  considerable,  by  both  methods.  In 
most  cases  the  deposit  is  extra-peritoneal,  and  is  situated  between  the 
folds  of  the  broad  ligament,  above  and  to  the  sides  of  the  vaginal  cul- 
de-sac.  It  has  generally  a  rounded  form,  though  with  less  convexity 
than  fibrous  and  ovarian  tumors.  Sometimes,  however,  the  tumor  is 
flat  below,  like  a  board.  It  seldom  exceeds  in  size  that  of  a  large  apjDle. ' 
In  fresh  exudations  the  sensation  produced  is  often  that  of  a  hard 
tumor  surrounded  by  a  softer  layer,  due  to  continued  succulence  of 
the  soft  parts.  In  a  few  weeks  they  may  reach  or  exceed  the  hardness 
of  a  fibroid  tumor.  The  older  the  tumor,  unless  suppuration  sets  in, 
the  less  sensitive  it  becomes.    Often  the  exudation  extends  to  the  jiel- 


624 


DISEASES  OF  CHILDBED. 


vie  walls.  The  uterus,  as  a  rule,  is  fixed,  and  in  cases  of  large  tu- 
mors becomes  pushed  toward  the  opposite  side,  while  as  a  consequence 
of  later  shrinkage  the  fundus  may  be  drawn  permanently  toward  the 
affected  side. 

The  cul-de-sac  of  the  vagina  is  rendered  broader  and  flatter  by  the 
pressure  of  the  deposit,  or,  when  the  tumor  is  deep  enough,  the  vagi- 
nal surface  may  be  rendered  convex.  Behind  the  uterus  the  exuda- 
tion is  as  it  were  flattened  antero-posteriorly,  and  in  some  cases  it  may 
be  felt  in  the  form  of  rigid  bands  between  the  posterior  ligaments 
which  inclose  the  cul-de-sac  of  Douglas.  The  ante-uterine  tumors 
have  a  spherical  shape,  and  depress  the  vagina  anteriorly. 

Tumors  situated  in  the  iliac  fossa  have  a  more  or  less  convex  form, 
and  may  be  of  such  considerable  size  that  the  swelling  may  be  recog- 
nized by  the  eye  through  the  abdominal  walls.  As  the  exudation  be- 
tween the  broad  ligaments  may  in  these  cases  have  been  slight  from 
the  beginning,  or  may  have  subsequently  disappeared  by  absorption, 
the  iliac  tumors  have  often  apparently  a  spontaneous  origin. 

Sometimes  the  uterus  is  surrounded  by  exudation,  and  the  entire 
pelvis  appears  as  though  it  were  a  mold  filled  with  a  solid  mass.  The 
fornix  is  then  often  pressed  downward,  and  irregular  rounded  masses 
are  to  be  felt  through  the  vaginal  walls. 

The  recognition  of  parametritic  tumors  through  the  abdominal 
coverings  is  possible  when  they  are  situated  above  Poupart's  ligament, 
in  the  upper  portion  of  the  broad  ligaments,  and  in  the  iliac  fossae. 

The  pain  and  the  functional  disturbances  in  the  pelvic  organs  de- 
pend upon  the  size  and  situation  of  these  inflammatory  deposits.  Of 
the  functional  troubles  may  be  mentioned  frequent  and  painful  mic- 
turition, obstinate  constipation,  and  difficult  defecation,  contractures 
of  the  ilio-psoas  muscles,  when  the  exudation  is  seated  beneath  the 
sheath  or  between  the  muscle  and  the  pelvic  bones,  disturbances  of 
motility  in  the  abductor  muscles,  paresis  of  the  lower  extremities,  and 
radiating  pains  in  the  upper  portion  of  the  thigh,  and  in  the  renal  and 
lumbar  regions,  produced  by  pressure  upon  the  obturator,  the  crural, 
the  cutaneous,  and  the  sciatic  nerves. 

So  long  as  fever  is  present,  the  exudation  rarely  diminishes.  If 
absorption  takes  place  in  one  point,  growth  almost  certainly  follows  in 
some  other  direction.  When,  however,  the  apyretic  period  is  reached, 
the  exudation,  as  a  rule,  disappears  rapidly,  so  that  often  in  the 
course  of  six  weeks  no  trace  of  its  existence  remains.  In  a  smaller 
number  the  solid  mass  may  persist  for  months,  or  even  years. 

After  the  fever  has  departed,  the  patient  usually  feels  well.  The 
sleep  and  appetite  return,  the  night-sweats  disappear,  the  pulse  often 
falls  to  50  or  60  beats,  and  the  temperature  is  in  many  cases  for  a  time 
subnormal  in  character. 

Where  the  fever  persists  for  from  five  to  six  weeks,  there  is  always 


PUERPERAL  FEVER. 


625 


a  suspicion  of  abscess  formation.  With  the  exception  of  afternoon 
fever  and  night-sweats,  the  patient  may  feel  very  comfortable.  Then 
the  exudation  becomes  sensitive,  the  spontaneous  pains  recur,  sleep  is 
lost,  and  locomotion,  defecation,  and  urination  occasion  acute  suffer- 
ing. The  fever  becomes  violent,  chills  announce  the  presence  of  pus, 
and  finally,  about  the  seventieth  or  eightieth  day,  perforation  of  the 
abscess  takes  place.  The  usual  seat  at  which  the  pus  is  discharged  is 
just  above  Poupart's  ligament ;  next  in  frequency  perforation  takes 
place  into  the  colon,  and  in  rare  instances  into  the  bladder^  the  uterus, 
and  vagina.  Fortunately  of  very  rare  occurrence  is  the  discharge  of  pus 
into  the  peritoneal  cavity,  which  is  naturally  followed  by  acute  peri- 
tonitis. Another  likewise  unfrequent  but  most  dangerous  accident  is 
the  septic  infection  of  the  abscess,  an  occurrence  referred  by  Olshau- 
sen  to  the  diffusion  of  intestinal  gases  through  the  walls  of  the  tumor. 

In  suppuration  of  parametritic  exudations  the  pus  commonly  forms 
in  small  scattered  collections,  and  rarely  gives  rise  to  large  abscesses. 

Although  parametritis  and  perimetritis  are  usually  found  associated 
together,  there  are  always  cases  in  which  the  one  form  of  inflamma- 
tion so  far  predominates  over  the  other  as  to  justify  an  attempt  to 
establish  a  clinical  distinction  between  them. 

In  the  beginning  of  the  attack,  sharp  pain,  high  fever,  and  tym- 
panitic distention  of  the  lower  abdomen  are  symptomatic  of  inflam- 
mation in  the  pelvic  peritonaeum.  Whether  the  cellular  tissue  is  si- 
multaneously implicated  can  only  be  determined  by  a  digital  examina- 
tion after  the  abdominal  sensitiveness,  has  subsided.  The  absence  of 
the  objective  signs  of  cellulitis  would  then  contribute  to  prove  that 
the  case  had  been  one  in  which  the  peritonaeum  had  been  in  the  main 
affected.  On  the  other  hand,  moderate  fever,  pain  elicited  only  on 
pressure,  and  tympanitic  distention  confined  to  the  colon,  coinciding 
with  exudation  between  the  folds  of  the  broad  ligament,  would  be 
indicative  of  a  nearly  pure  cellulitis. 

A  palpable  exudation  is  by  no  means  the  necessary  product  of  peri- 
toneal inflammation.  Indeed,  in  many  cases,  the  distinctive  symp- 
toms of  the  latter  may  be  present  for  from  four  to  eight  days,  and  may 
then  subside  without  leaving  a  trace  of  its  existence  at  the  pelvic  brim. 

The  demonstration  of  a  fluid  effusion  by  noting  the  change  of  level 
upon  shifting  the  position  of  the  patient  is  rarely  possible,  either  be- 
cause the  quantity  is  too  small,  or  because  it  quickly  becomes  confined 
by  pseudo-membranous  adhesions  between  the  intestines. 

Bandl*  mentions  as  a  sign  of  local  peritonitis,  sometimes  notice- 
able, a  number  of  resistant  points  or  tumors  near  the  pelvic  brim,  or 
above  one  of  the  iliac  fossae,  due  to  a  matting  together  of  the  intes- 
tines or  to  their  adhesion  to  the  uterine  appendages.    They  are  distin- 

*  Bandl,  "  Handbuch  der  Frauenkrankheiten,"  red.  von  Billroth,  5te  Abschnitt,  p. 
129. 

40 


626 


DISEASES  OF  CHILDBED. 


guished  from  solid  tumors  by  their  emitting  a  tympanitic  sound  upon 
percussion  and  by  their  changing  position  in  consequence  of  an  accu- 
mulation of  urine  in  the  bladder,  or  of  faeces  or  gases  in  the  bowels. 
Again,  all  tumors  may  be  reckoned  as  intra-peritoneal  which  very  rap- 
idly form  behind  or  to  the  side  of  the  uterus  from  inclosed  exudation 
products,  and  which  at  the  same  time  rise  far  above  the  level  of  the 
pelvic  brim.  If,  however,  they  start  from  the  cul-de-sac  of  Douglas, 
and  do  not  much  exceed  the  linea  terminalis,'  or  if  they  occupy  an 
iliac  fossa,  it  becomes  very  difficult  to  decide  whether  they  are  of  intra- 
or  extra-peritoneal  origin.  The  peritoneal  exudation,  however,  long 
remains  soft  and  fluctuating.  It  arises,  as  a  rule,  behind  the  uterus, 
and  does  not  exhibit  a  tendency  to  spread  to  the  sides  or  the  anterior 
or  posterior  pelvic  walls. 

Still  more  difficult  is  it  to  decide  as  to  the  seat  of  exudations  met 
with  beneath  the  abdominal  walls.  When  diffused  and  continuous 
with  a  pelvic  deposit,  the  diagnosis  is  uncertain.  It  is  only  safe  to 
assume  the  peritoneal  origin  of  extravasations  of  a  rounded  form,  of  a 
fluctuating  consistence,  and  when  they  are  situated  high  up  and  are 
disconnected  from  exudation  at  the  pelvic  brim.  An  opening  of  the 
abscess  through  the  navel  would  indicate  a  peritoneal  source,  while 
the  discharge  through  the  abdominal  parietes  would  point  to  a  seat  in 
the  connective  tissue. 

After  the  perforation  of  an  abscess  the  fever  and  pain  subside,  the 
wound,  if  external,  either  closes  in  the  course  of  one  or  two  weeks,  or 
fistulas  form  which  become  the  source  of  protracted  suppuration. 

In  psoas  abscesses  the  exudation  extends  beneath  the  sheath  of  the 
muscle,  or  between  the  iliacus  and  the  bone.  In  puerperal  patients 
they  proceed  from  an  inflammation  originating  in  the  broad  ligament. 
They  are  situated  too  deep  to  be  easily  palpated.  The  pains  they  oc- 
casion are  referred  rather  to  the  hip  or  knee  than  to  the  abdomen. 
The  contracture  of  the  psoas  muscle  furnishes  a  diagnostic  sign  which 
distinguishes  this  form  from  the  superficial  abscesses  of  the  iliac  fossae. 
The  pus  eventually  is  discharged  beneath  Poupart's  ligament,  in  the 
lower  portion  of  the  inguinal  fossa,  at  some  point  upon  the  crest  of 
the  ilium,  or  exceptionally  along  the  thigh.  Often  the  discharge  is 
maintained  for  months. 

General  Peritonitis. — This  form  generally  begins  with  the  usual 
symptoms  of  pelvic  inflammation,  but  the  tenderness,  which  at  first 
was  limited  to  the  side  of  the  uterus,  gradually  spreads  over  the  entire 
abdomen.  The  abdominal  pain  is  of  a  tearing,  lancinating,  some- 
times colicky  character.  It  is  increased  by  the  slightest  bodily  move- 
ment, by  jarring  of  the  bed,  or  even  by  the  weight  of  the  bedclothes. 

As  a  consequence  of  the  peritoneal  inflammation  and  of  the  accom- 
panying exudation,  the  muscular  walls  of  the  bowels  become  paralyzed, 
and  tympanitic  distention  results  from  the  accumulation  of  gases.  In 


PUERPERAL  FEVER. 


627 


the  dependent  portions  of  the  peritoneal  cavity  it  is  often  possible  to 
demonstrate  by  percussion  the  presence  of  fluid  exudation,  though  dis- 
tinct fluctuation  is  rarely  to  be  made  out.  The  size  of  the  abdomen  is 
due  much  more  to  the  tympanites  than  to  the  amount  of  effusion. 
Sometimes  the  liver,  with  the  diaphragm,  is  pushed  by  the  swollen 
bowels  to  the  level  of  the  fourth  or  third  rib,  and  exercises  such  a 
degree  of  compression  upon  the  posterior  portion  of  the  lungs  as  to 
place  the  patient  in  danger  of  suffocation.  The  respirations  are  jerfcy 
and  attended  with  a  moaning  sound. 

The  loss  of  muscular  power  in  the  intestines  permits  the  contents 
of  the  middle  portion  to  pass  unchecked  toward  the  duodenum,  and 
thence,  upon  accidental  contractions  of  the  abdomen,  they  may  pass 
to  the  stomach  and  be  ejected  by  vomiting.  The  first  vomited  mat- 
ter has  a  dark-green  color,  and  that  ejected  afterward  presents  the  color 
of  intestinal  matter.  Constipation  at  the  outset  may  be  subsequently 
followed  by  colliquative  diarrhoea. 
^  The  fever  begins,  as  a  rule,  though  not  always,  with  an  intense 
chill,  the  temperature  rises  to  104°,  and  the  pul^e  becomes  small,  hard, 
and  resistant.  Its  frequency  rapidly  increases,  varying  from  120  to 
160  beats  to  the  minute.  The  skin  is  sometimes  dry,  sometimes  drip- 
ping with  perspiration.  In  fatal  cases,  as  the  end  approaches,  the 
temperature  frequently  falls,  while  the  pulse  becomes  more  rapid,  the 
face  assumes  a  pinched,  anxious  expression,  sweat  gathers  upon  the 
forehead,  the  extremities  grow  icy  cold,  and  the  patient  dies  in  col- 
lapse. The  duration  of  peritonitis  averages  not  more  than  from  four 
to  six  days. 

In  cases  of  recovery  the  pulse  improves,  the  vomiting  ceases,  and 
the  tympanites  disappears.  The  diffuse  exudation  then  becomes  con- 
verted into  circumscribed  tumors,  which  on  palpation  are  felt  on  the 
side  of  the  pelvis  and  extending  upward  to  the  level  of  the  umbilicus. 
Upon  internal  examination  the  uterus  is  often  found  depressed  by  the 
weight  of  the  fluid,  which  likewise  may  bulge  the  cul-de-sac  of  Doug- 
las into  the  pelvic  cavity.  Sometimes  the  exudation  may  become  en- 
cysted above  the  pelvis,  and  leave  the  contents  of  the  latter  free.  In 
still  other  cases  the  uterus  may  become  attached  high  up  to  the  ab- 
dominal walls,  so  that  the  vaginal  portion  disappears,  and  the  os  is 
reached  with  difficulty. 

1'he  peritoneal  exudation  may,  as  in  pelvic  inflammations,  become 
absorbed  and  disappear.  When,  however,  it  is  surrounded  by  loops  of 
intestines  it  is  apt  to  undergo  purulent  and  septic  changes,  and  the 
abscesses  may  then  become  discolored  and  filled  with  stinking  gases. 
The  patient,  whose  previous  improvement  has  been  watched  with  de- 
light, now  loses  appetite,  the  pulse  becomes  frequent,  the  strength 
fails,  and  death  may  follow  from  septic  fever  or  from  rupture  of  abscess 
gk  into  the  abdominal  cavity. 


628 


DISEASES  OF  CHILDBED. 


In  the  pyaemic  form — a  still  more  deadly  variety  of  peritonitis — 
the  symptoms  differ  materially  from  those  which  have  been  recounted. 
As,  however,  it  constitutes  only  a  single  one  of  the  pathological  changes 
connected  with  the  poisoning  of  the  blood  through  the  lymphatic  sys- 
tem, its  consideration  belongs  properly  to  the  study  of  septic  infec- 
tion. 

Septicaemia  Lymphatica. — The  symptoms  of  blood-poisoning  in  the 
injections  diseases  of  childbed  vary  to  a  considerable  extent  according 
to  the  channel  through  which  the  septic  germs  enter  the  general  cir- 
culation. In  the  murderous  epidemics  which  prevail  in  lying-in  hos- 
pitals the  lymphatics  are,  as  a  rule,  the  vessels  primarily  invaded. 
It  is  to  this  form  that  belong  the  cases  already  described,  where,  with 
diphtheritic  patches  upon  the  utero-vaginal  canal,  and  sero-purulent 
oedema  of  the  parametrium,  there  are  associated  pyaemic  peritonitis 
and  deformation  of  the  blood-corpuscles  ;  or  where,  following  the 
migrations  of  the  round  bacteria,  the  serous  cavities  become  succes- 
sively involved,  septic  vegetations  gather  upon  the  heart,  and  the  glom- 
eruli of  the  kidneys  become  choked  with  micrococci.  The  lymphatic 
form  of  septicaemia  develops  soon  after  labor,  and  is  always  ushered  in 
by  a  chill.  The  temperature  rises  to  104°  or  even  higher,  and  the 
pulse  is  thin  and  frequent.  The  abdomen  swells  rapidly,  without  being 
especially  painful.  Indeed,  painless  distention  of  the  intestines  is  one 
of  the  characteristics  of  an  acute  invasion  of  the  lymphatics.  Peri- 
toneal effusion  is  absent  in  cases  which  run  a  rapid  course,  and  is  dis- 
tinctly recognizable  only  in  a  peritonitis  of  long  continuance.  The 
effusion  is  not  so  much  due  to  exudation  as  to  a  transudation  of  serum 
with  which  micrococci  are  commingled.  At  the  same  time  the  tongue 
is  moist,  but  slightly  coated,  and  at  times  quite  clean.  Sometimes 
there  is  diarrhoea  due  to  catarrh  or  to  a  diphtheritic  affection  of  the 
colon.  When  the  bowels  have  been  constipated,  the  administration  of 
a  purgative  may  provoke  discharges  which  it  may  be  found  difficult  to 
arrest.  The  skin  is  bathed  in  perspiration.  At  the  beginning  and 
during  the  course  of  the  disease,  bleeding  at  the  nose  is  of  not  infre- 
quent recurrence. 

Toward  the  end  the  pulse  runs  up  to  140  to  160  beats,  while  in 
many  cases  the  temperature  falls.  Immediately  after  death  the  heat 
of  the  body  may  for  a  short  time  exceed  the  highest  point  reached 
during  life.  The  respirations  are  superficial  and  jerky.  In  many  in- 
stances the  face,  the  neck,  and  the  fingers  are  blue  from  defective 
oxygenation  of  the  blood.  At  the  same  time  the  skin  becomes  clammy 
and  the  extremities  cold. 

The  sensorium,  in  cases  which  run  a  rapid  course,  is  usually  affected 
at  an  early  period.  The  patients  appear  somnolent,  are  restless  in  bed, 
have  light  delirium,  and  respond  only  when  spoken  to  loudly.  As  a 
rule,  they  make  but  little  complaint,  and,  were  it  not  for  the  dyspnoea, 


PUERPERAL  FEVER. 


629 


would  have  nothing  to  disturb  their  sense  of  comfort.  Very  few, 
even  as  death  approaches,  have  any  idea  of  the  danger  that  threatens 
them.  Now  and  then,  in  place  of  stupor,  great  restlessness,  and  even 
a  maniacal  condition,  is  developed.  Albumen  is  usually  found  in  the 
urine. 

Pleurisy,  so  frequently  associated  with  lymphatic  septicaemia,  is 
frequently  double,  more  rarely  single,  and  begins,  as  a  rule,  with 
sharp  pain  in  the  side  and  an  aggravation  of  the  previous  dyspnoea. 
Pericarditis  is  less  frequent,  and  occurs  usually  without  symptoms 
toward  the  close  of  life.  The  joint  affections  are  characterized  by 
redness  and  swelling,  and  by  pain  which  is  sometimes  so  great  that 
touching  the  inflamed  part  suffices  to  arouse  the  patient  from  sopor. 
Sometimes  fluctuation  is  felt,  but  death  occurs  before  perforation  and 
discharge  of  the  pus. 

The  most  frequent  ending  is  death,  which  follows  in  from  two  to 
twenty-one  days,  and,  as  a  rule,  between  four  and  seven  days.  Ee- 
covery  is,  however,  possible. 

Septicaemia  Venosa  (phlebitis  uterina,  pyaemia  metastatica). — The 
putrid  infection  of  a  thrombus  at  the  placental  site  may  take  place 
within  twenty-four  to  forty-eight  hours  after  labor.  Usually,  how- 
ever, the  approach  is  insidious,  and  the  disease  develops  from  an  ap- 
parently insignificant  endometritis  or  parametritis  ;  or  the  patient, 
with  the  exception  perhaps  of  a  tired  feeling,  of  slight  chilly  sensa- 
tions, and  of  profuse  perspiration,  may  not  have  been  conscious  of  any 
indisposition  for  days  preceding  the  attack,  or  even  until  the  first 
getting  up  from  childbed.  The  initial  chill  in  typical  cases  is  char- 
acterized by  its  violence  and  duration.  In  some  cases  it  may  last  for 
hours.  It  is  accompanied  and  followed  by  high  temperature,  the 
febrile  attack  ending  with  profuse  perspiration  as  in  intermittent  fever, 
with  which  it  is  apt  to  be  confounded.  The  fall  in  temperature  often 
assumes  the  form  of  a  prolonged  remission. 

In  many  cases  the  pulse  rises  and  falls  with  the  variations  in  the 
body-heat,  while  in  others  it  remains  permanently  above  the  average. 
A  frequent  pulse  is  always  a  suspicious  symptom  in  childbed,  even 
where  the  other  symptoms  are  apparently  normal. 

Erratic  chills  announce  the  lodgment  of  emboli  in  distant  organs. 
With  the  formation  of  metastatic  abscesses  in  the  lungs  and  other 
l)arenchymatous  organs,  the  typical  character  of  the  disease  changes. 
In  place  of  chills  occurring  at  irregular  intervals,  followed  by  remis- 
sions and  periods  of  apparent  improvement,  the  fever  is  continuous, 
the  pulse  becomes  small  and  rapid,  while  sopor,  slight  delirium,  a  dry 
skin,  a  dry,  brown,  cracked  tongue,  and  a  moderately  tympanitic  ab- 
domen give  the  case  the  appearance  of  one  of  typhus  fever. 

Peritonitis  is  present  in  hardly  one  third  of  the  cases.  The  abdo- 
men is  therefore  flat  and  soft,  and  often  is  not  sensitive  upon  pressure. 


630 


DISEASES  OF  CHILDBED. 


Icterus,  due  to  disintegration  of  the  blood-corpuscles,  is  an  ominous 
symptom. 

Death  usually  occurs  in  the  second  or  third  week.  In  the  typhus- 
like cases,  however,  it  may  follow  the  first  attack  speedily.  Eecovery 
is  possible  where  the  organs  secondarily  affected  are  not  of  too  great 
importance. 

A  combination  of  the  lymphatic  and  venous  forms  of  septicaemia 
is  not  uncommon  in  cases  running  a  protracted  course. 

Pure  Septicsemia. — Under  the  title  of  pure  septiccemia  should  be 
placed  cases  in  which  the  absorption  of  putrid  materials  into  the 
blood  gives  rise  to  symptoms  of  intense  blood-poisoning  without  the 
development  of  local  lesions.  A  common  example  of  this  form  is  met 
with  in  the  fever  which  results  from  the  presence  in  the  uterus  of 
decomposing  coagula  or  portions  of  retained  ovum,  the  fever  subsid- 
ing with  the  removal  of  the  disturbing  cause.  In  like  manner  we 
sometimes  meet  with  cases  of  intense  septic  poisoning  followed  by 
speedy  death,  in  which  the  post-mortem  examination  reveals  only 
changes  in  the  blood  and  softening  of  the  parenchymatous  organs. 
The  symptoms  are  often  similar  to  those  produced  by  the  injection  of 
putrid  materials  containing  rod- like  bacteria  into  the  vessels  of  ani- 
mals. As  the  long  bacteria  do  not  possess  the  capacity  of  self-repro- 
duction in  the  blood,  to  produce  fatal  results  the  quantity  of  putrid 
fluid  injected  must  be  large  or  be  frequently  repeated.  This  form  is 
said  not  to  be  inoculable. 


CHAPTEE  XXXVI. 

PUEBPEBAL  FE VEB.—{  Continued.) 

Causes. — The  atmosphere. — Relations  to  zymotic  diseases. — Season  of  year. — Social  state. 
— The  prevention  of  puerperal  fever, — The  treatment  of  puerperal  fever. — Vaginal 
and  uterine  injections ;  opium ;  leeches  ;  laxatives ;  quinine  ;  salicylate  of  sodium  ; 
veratrum  viride  ;  digitalis;  alcohol;  cold. — Treatment  of  peritoneal  effusions. 

Causes  of  Puerperal  Fever. 

The  Atmosphere. — The  effect  of  a  poisoned  state  of  the  atmosphere 
is  best  observed  in  the  so-called  nosocomial  malaria  of  hospitals.  At 
Belle vue  and  at  the  Maternity  Hospitals  I  have  had  frequent  occasion 
to  witness  febrile  outbreaks  among  the  patients  in  the  lying-in  service, 
which  were  instantly  arrested  by  closing  the  tainted  ward  and  trans- 
ferring the  inmates  to  a  wholesome  locality.  As  at  these  times  the 
nurses,  the  bedding,  and  the  utensils  remain  unchanged,  it  is  fair  to 
assume  that  the  previous  unhealthy  condition  was  not  due  to  the  trans- 
fer of  the  poison  from  patient  to  patient  by  the  attendants,  but  by 
something  residing  in  the  air  of  the  vacated  apartment.    In  the  inquiry 


PUERPERAL  FEVER. 


631 


as  to  the  production  of  this  condition,  it  can  be  assumed  that  it  is  not 
caused  by  aggregation  alone.  The  medical  wards,  always  crowded,  have 
been  in  time  of  need  safe  receptacles  for  lying-in  j)atients.  It  is  cer- 
tainly not  due  to  the  presence  of  what  are  generally  regarded  as  the  or- 
dinary constituents  of  the  atmosphere.  We  must,  therefore,  look  for 
some  additional  element  capable  of  unfavorably  affecting  the  economy. 
When  the  disturbance  produced  by  nosocomial  malaria  is  not  arrested 
by  change  of  locality,  and  the  golden  moment  is  allowed  to  slip  by, 
the  secretions  of  the  patient  affected  become  inoculable.  Under  such 
circumstances  the  epidemic  spreads  rapidly,  and  assumes  continuously 
a  more  and  more  severe  type.  If,  during  such  an  epidemic,  the  exter- 
nal genitals  be  carefully  watched,  diphtheritic  patches  may  now  and 
then  be  observed.  At  first  these  patches  may  not  be  of  any  special 
clinical  importance.  It  is  possible  that  they  may  rapidly  clear  off, 
and  thus  come  to  be  regarded  as  of  little  consequence.  When,  at 
length,  the  epidemic  has  assumed  a  pestilential  form,  these  patches, 
which  may  make  their  appearance  in  isolated  cases  at  any  time  in  a 
hospital,  are  rarely  absent.  I  have  already  dwelt  upon  the  com^^osi- 
tion  of  these  patches,  not  because  I  believe  that  they  are  essential  to 
puerperal  fever,  but  because  their  presence  tells  the  tale  of  what  it  is 
in  the  atmosphere  which  accomplishes  the  charnel-house  work.  Con- 
ditions have  been  present  in  the  air  to  favor  the  multiplication  of  bac- 
teria, and  have  fitted  them  to  become  the  active  producers  of  disease. 
Can  we  doubt  this  ?  First,  the  epidemic  is  mild.  If  a  patient,  how- 
ever, dies,  her  tissues  and  secretions  are  filled  with  bacteria,  as  has 
been  described.  Then  the  epidemic  becomes  virulent,  and  the  lesions 
of  the  generative  apparatus,  especially  of  the  external  organs,  which 
are  most  exposed  to  the  air,  become  covered  with  patches  which  are 
found  to  swarm  with  micrococci.  I  can  not,  under  the  conditions 
named,  but  consider  it  more  in  accordance  with  ordinary  scientific 
reasoning  to  conclude  that  the  micrococci  played  an  important  part  in 
the  production  of  puerperal  fever,  than  that  the  puerperal  fever  pro- 
duced the  micrococci. 

To  be  sure,  bacteria  or  their  spores  are  always  present  in  the  atmos- 
phere, and  it  may  be  fairly  asked  how  patients  are  ever  spared  from 
their  perverse  industry.  The  answer  is,  that  they  are  not  always  equally 
active  for  evil.  Buchholz  found  that  the  same  bacteria,  developed  in 
Cohn's  fluid,  offered  more  resistance  to  carbolic  and  salicylic  acids 
than  those  cultivated  in  an  analogous  fluid  which  he  had  adopted. 
Distilled  water  renders  the  action  of  bacteria  extremely  feeble.  In 
experiments  upon  animals,  the  results  obtained  with  septic  fluids  de- 
pend in  no  ordinary  degree  upon  the  age  of  the  fluid,  the  material 
from  which  it  is  formed,  and  the  conditions  under  which  it  is  gener- 
ated. Micrococci  multiply  in  hospitals  when  organic  materials  favor- 
able to  their  growth  are  present  in  sufficient  quantities.    Kobin  and 


632 


DISEASES  OF  CHILDBED. 


others  have  demonstrated  the  existence  of  albuminoid  matters  in  water 
condensed  upon  vessels  containing  freezing  mixtures,  and  placed  in 
overcrowded  wards  of  hospitals.  When  the  results  of  crowding  become 
manifest,  these  albuminoid  matters  not  only  impart  a  peculiar  fetid 
odor  and  putrefy  with  great  rapidity,  but  rapidly  impart  putrefaction 
to  normal  blood  and  healthy  muscle  with  which  they  are  brought  in 
contact.*  Micrococci  both  cause  putrefaction  and  serve  as  the  car- 
riers of  septic  virus.  Hueter  found  putrid  blood  a  most  favorable 
fluid  for  septic  experiments.  It  was  noticeable  in  Bellevue  Hospital 
that  febrile  outbreaks  always  arose  in,  and  were  usually  confined  to, 
the  ward  in  the  hospital  which,  by  a  bad  arrangement,  was  assigned 
to  patients  for  the  first  four  or  five  days  following  confinement — i.  e., 
during  the  period  of  the  lochia  cruenta.  As  puerperal  fever  is  rare 
after  the  fifth  day,  this  at  first  sight  would  seem  natural.  But  if  a 
patient  was  transferred  directly  after  confinement,  during  one  of  these 
unhealthy  periods,  to  the  ward  containing  the  patients  who  had  passed 
the  first  five  days,  but  had  not  completed  the  ten  days,  she  would 
escape  the  fever.  It  was  always  the  same  ward  that  required  to  be 
disinfected.  In  a  communicating  apartment  all  the  confinements  took 
place  ;  and  at  all  times,  therefore,  the  conditions  were  present  for  load- 
ing the  atmosphere  with  the  products  of  decomposing  blood.  In  the 
summer  months,  as  long  as  the  windows  were  open  all  the  time,  the 
joatients  enjoyed  immunity  from  nosocomial  malaria.  In  the  autumn, 
so  soon  as  it  became  necessary  to  close  the  windows  partially  on  ac- 
count of  the  cool  nights,  it  was  not  uncommon  for  the  more  trivial 
disturbances,  such  as  so-called  milk-fever,  the  hospital-pulse,  and  ca- 
tarrhal affections  of  the  genitalia,  to  manifest  themselves.  Through 
the  months  of  February,  March,  and  April  the  mortality  was  usually 
greatest.  During  the  winter  months  there  was,  as  a  rule,  crowding 
of  patients,  insufficient  ventilation,  the  saturation  of  the  air  with  albu- 
minoid materials  chiefly  derived  from  blood,  which,  under  the  further- 
ing influence  of  the  heat  requisite  to  make  the  wards  comfortable, 
entered  readily  into  decomposition.  That  the  latter  winter  months 
should  prove  the  most  perilous,  is  in  accordance  not  only  with  the 
theory  of  continuous  accumulation,  but  with  the  experimental  fact 
that  weeks  sometimes  elapse  before  a  decomposing  substance  acquires 
the  highest  degree  of  virulence. 

Apart  from  the  nosocomial  malaria  of  hospitals,  there  is  reason  to 
believe  in  the  influence  at  times  of  certain  general  widespread  atmos- 
pheric states  which  aft'ect  the  entire  community.  In  the  year  1871 
the  mortality  from  childbed  in  New  York  was  399  ;  in  1872,  503  ;  in 
1873,  431  ;  in  1874,  439  ;  and  in  1875,  420.  Now,  the  excess  in  the 
deaths  for  1872  was  due  wholly  to  an  increase  in  the  cases  of  me- 
tria,  those  from  ordinary  accidents  remaining  nearly  the  same  as  in  the 

*  "Le9ons  sur  Ics  humcurs,"  Paris,  1867,  p.  195. 


PUERPERAL  FEVER. 


633 


preceding  years.  The  disease  certainly  did  not  extend  into  the  city 
from  the  hospitals  serving  as  foci,  for  the  mortality  at  Belle vue 
Hospital  was  hardly  more  than  half  the  usual  average.  There  was 
no  especial  mortality  that  year  from  either  diphtheria,  erysipelas, 
or  scarlatina,  but  the  aggregate  mortality  was  the  largest  known  in 
the  history  of  the  city.  There  are  no  positive  data  connecting  the 
civil  deaths  from  puerperal  fever  in  1872  with  parasiticism,  but  the 
prevalence  of  epizootics,  of  epidemic  catarrhal  affections,  of  peculiarly 
fatal  forms  of  pneumonia,  and  other  diseases  which  are  now  attributed 
to  the  presence  of  minute  organisms  in  the  atmosphere,  renders  such 
a  source  highly  probable. 

It  is  proper  to  say  here  that,  though  the  argument  is  very  strong 
in  favor  of  regarding  the  genitalia  of  puerperal  women  as  the  exclusive 
point  of  entry  of  infectious  materials  into  the  system,  it  seems  impos- 
sible at  the  present  time  to  make  all  the  facts  coincide  with  such  a 
theory.  I  have  the  records  of  a  number  of  cases  occurring  during  an 
epidemic  of  puerperal  fever,  in  which  patients  were  either  attacked 
with  fever  previous  to  parturition,  or  in  whose  cases  the  unusual 
length  of  labor,  the  frequency  of  post-partum  haemorrhage,  and  the 
imperfect  contraction  of  the  uterus  immediately  after  confinement 
were  signs  of  some  abnormal  influence  exercised  upon  the  economy  at 
an  early  period  of  labor,  previous  to  the  existence  of  traumatism. 
That  deleterious  materials  may  find  other  channels  for  entering  the 
system  than  a  wounded  surface,  is  evidenced  by  the  cachectic  condition 
not  unfrequently  produced  in  physicians  by  too  assiduous  attendance 
in  dissecting-rooms  and  places  in  which  post-mortem  examinations  are 
conducted.  One  severe  and  rapidly  fatal  case  of  puerperal  fever,  which 
occurred  in  Bellevue  Hos|)ital,  I  find  it  impossible  to  attribute  to  any 
other  cause  than  that  the  woman,  for  five  months  previous  to  her  con- 
finement, served  as  a  helper  in  a  lying-in  ward.  The  post-mortem 
examination  disclosed  no  special  local  lesions,  but  her  symptoms  were 
those  of  intense  septicaemia.  It  does  not  yet  seem  quite  time  to  give 
up  the  idea  that,  under  exceptional  circumstances,  the  respiratory, 
and  probably  the  digestive,  tracts  may  allow  the  passage  of  materials 
of  a  septic  character. 

Inoculation. — Another  and  frequent  source  of  puerperal  fever  is 
by  direct  inoculation.  Any  material  of  a  septic  character,  introduced 
into  the  genital  passages  of  a  woman  during  or  after  confinement,  may 
produce  a  general  infection  of  the  system.  But  the  point  upon  which 
I  wish  especially  to  dwell  is  that  it  is  possible  to  trace  epidemics  of 
puerperal  fever  directly  to  carrying  puerperal  poison  from  patient  to 
patient,  through  the  medium  of  attendants.  In  such  cases  changes 
in  wards  and  the  most  rigid  sanitary  precautions  avail  but  little,  as 
long  as  the  affected  ^er50/^7^e?  is  continued  in  charge.  Unless  this  fact 
is  fully  recognized,  all  the  cleverest  devices  in  hospital  construction 


634 


DISEASES  OF  CHILDBED. 


will  fail  to  prevent  the  occurrence  of  disasters.  In  epidemics  this 
source  of  danger  is  especially  to  be  guarded  against,  as  septic  poison  is 
increased  in  intensity  by  successive  inoculations.  Davaine  *  showed 
that  when  a  number  of  animals  were  poisoned,  the  one  from  the  other, 
while  from  ten  to  fifteen  drops  of  putrid  blood  were  required  to  pro- 
duce death  in  the  first  animal,  one  ten-trillionth  part  of  a  drop  was 
sufficient  in  the  twenty-fifth  animal  of  the  series,  and  in  puerperal- 
fever  epidemics  a  similar  augmentation  in  the  deadliness  of  the  poisons 
generated  by  patients  is  observed. 

The  nurses  in  hospitals  and  in  private  practice  are  usually  the 
carriers  of  contagion.  In  studying  the  records  of  New  York  City  for 
nine  years,  I  find,  however,  that  the  occurrence  of  two  deaths  from 
puerperal  disease,  following  one  another  so  closely  as  to  lead  to  the 
suspicion  of  inoculation,  occurred  to  thirty  physicians  ;  a  sequence  of 
three  case  occurred  in  the  practice  of  three  physicians  ;  one  physician 
lost  three  cases,  and  afterward  two,  in  succession  ;  one  physician  had 
once  two  deaths,  once  three  deaths,  and  twice  four  deaths,  following 
one  anothei; ;  finally,  a  physician  reported  once  a  loss  of  two  cases 
near  together,  then  of  six  patients  in  six  months,  and  then  of  six 
patients  in  six  weeks.  Thus  in  the  practice  of  more  than  twelve 
hundred  physicians,  in  nine  years,  I  find,  excluding  cases  occurring 
in  hospitals,  that  the  experience  of  thirty-six  only  lends  color  to 
the  idea  that  puerperal  fever  is  due  to  criminal  neglect  on  the 
part  of  the  medical  profession.  Undoubtedly  in  many  of  these 
cases,  too,  the  responsibility  is  only  apparent,  as  when  a  practi- 
tioner has,  for  example,  had  the  misfortune  to  lose  in  one  week  a 
woman  from  puerperal  convulsions,  and  another  in  the  following 
week  from  placental  haemorrhage.  Singularly  enough,  not  one  of 
the  sequences  mentioned  occurred  in  the  practice  of  a  physician 
connected  with  a  lying-in  hospital.  In  face  of  the  charge  that  the 
physicians  holding  obstetrical  appointments  in  public  institutions 
are  active  disseminators  of  puerperal  fever  through  populous  com- 
munities, I  find  that  the  total  loss  from  all  puerperal  causes,  oc- 
curring in  the  private  practice  of  ten  physicians  intimately  asso- 
ciated with  such  institutions,  numbered,  during  the  nine  years, 
but  twenty-one  cases.  Of  these,  thirteen  were  the  result  of  or- 
dinary accidents,  and  only  eight  cases  of  metria  proper,  of  which 
one  was  developed  before  the  physician  was  called  in  attendance  ; 
whereas  a  single  physician,  holding  no  hospital  appointment,  lost  dur- 
ing the  same  time  twenty-seven  cases,  of  which  twenty-one  were  cases 
of  metria. 

I  have  been  interested  in  endeavoring  to  ascertain  how  far  ex- 
perience corresponds  with  Scmelweiss's  theory  that  puerperal  fever 
owes  its  origin  to  poisonous  materials  obtained  from  dissecting-rooms, 
*  Report  before  the  Academic  dc  Medecine,  September  17,  1872. 


PUERPERAL  FEVER. 


635 


and  introduced  into  the  genital  canal  by  the  hands  of  physicians  at- 
tending cases  of  labor.  With  this  view  I  have  made  personal  applica- 
tion to  a  number  of  gentlemen  who  have  engaged  in  midwifery  practice 
while  performing  the  functions  of  demonstrators  of  anatomy  in  our 
medical  schools.  Dr.  H.  B.  Sands,  of  the  College  of  Physicians  and 
Surgeons,  reports  that,  in  the  five  years  during  which  he  held  the  office 
of  demonstrator,  he  attended  about  sixty  cases  of  labor.  All  did  well. 
He  lost  his  first  patient,  from  childbed,  a  short  time  after  he  had  re- 
signed his  position  in  the  dissecting-room.  Dr.  J.  W.  Wright,  the 
present  Professor  of  Surgery  in  the  Medical  Department  of  the  New 
York  University,  who  held  for  one  year  the  position  of  Demonstrator 
in  the  Woman's  College,  writes  me  that  during  the  year,  I  attended 
one  hundred  and  four  cases,  including  twenty-two  forceps  cases,  two 
of  craniotomy,  two  of  podalic  version,  and  four  of  breech  presentation. 
Of  this  number  I  lost  two  cases,  one  from  phlegmasia  dolens  compli- 
cating uraemia,  from  both  of  which  troubles  the  patient  had  suffered 
during  her  previous  labor,  and  one  from  double  pneumonia,  the  result 
of  unusual  exposure  following  confinement.  Out  of  these  one  hun- 
dred and  four  cases,  I  can  recall  but  three  or  four  cases  of  metritis, 
and  those  of  a  mild  character ;  I  have  never  thought  they  had  any 
special  connection  with  my  duties  in  the  dissecting-room.  I  may  add 
that  for  ten  years  I  have  attended  a  pretty  large  number  of  confine- 
ments each  year,  and  that  during  the  whole  of  this  time  I  have  been 
in  the  habit  of  making  autopsies  as  occasion  has  offered,  and  of  han- 
dling and  examining  pathological  specimens  both  in  and  out  of  the 
dissecting-room,  notwithstanding  which,  my  death-record  among  this 
class  of  cases  has  been  unusually  low."  Dr.  Samuel  B.  Ward,  formerly 
Demonstrator  at  the  Woman's  College,  at  present  Professor  of  Surgery 
in  the  Medical  School  at  Albany,  writes  :  While  I  was  daily  in  the 
dissecting-room,  during  the  winter  sessions  of  the  school  from  1868  to 
1872,  I  attended  thirty-two  confinements,  of  which  I  have  notes.  All 
of  the  patients  recovered,  nor  did  any  of  them  suffer  from  any  com- 
plication that  could  be  traced  to  infection."  It  is  familiarly  known 
that,  after  Semelweiss  had  introduced  the  practice,  among  the  physi- 
cians attending  patients  at  the  large  lying-in  hospital  in  Vienna,  of 
washing  the  hands  in  a  solution  of  chloride  of  lime,  there  was  a  great 
diminution  in  the  mortality  which  prevailed,  notwithstanding  which 
G.  Braun  reports,  however,  that  in  1857,  in  the  month  of  July,  in  two 
hundred  and  forty-five  deliveries  there  were  seventeen  deaths.  The 
following  month  Professor  Klein  gave  orders  to  suspend  the  use  of 
disinfectants.  By  chance,  in  August  there  were  only  six  deaths  out 
of  two  hundred  and  fifty  confinements,  and  in  September,  of  two 
hundred  and  seventy-five  patients,  none  died.  From  1857  to  1860  the 
mortality  was  slight,  though  disinfectants  were  not  used,  while  during 
the  three  following  years,  in  spite  of  the  systematic  and  persistent 


636 


DISEASES  OF  CHILDBED. 


employment  of  these  agents,  the  death-rate  once  more  assumed  formi- 
dable proportions.* 

Of  course,  I  do  not  wish  to  underrate  the  importance  of  Semel- 
weiss's  labors.  There  is  no  question  but  that  it  is  a  perilous  experiment 
to  pass  from  the  dissecting-room  to  a  patient  in  labor,  without  em- 
ploying rigorous  measures  to  disinfect  the  hands  and  all  parts  of  the 
person  brought  into  contact  with  the  dead  body.  But  it  is  well  to 
call  attention  to  the  fact  that  puerperal  fever  is  not  due  to  any  single, 
simple  cause,  nor  can  be  elfectually  guarded  against  by  a  single  pre- 
caution ;  and  again  that  cadaveric  poison  does  not  of  necessity  exist  in 
every  cadaver  examined.  Haussmann  found  that  injections  into  the 
vagina  of  gravid  rabbits,  in  the  latter  half  of  pregnancy,  of  serum 
from  the  corpse  of  a  person  who  had  not  died  of  septicaemia,  produced 
no  fatal  results,  while  rapid  death  resulted  from  injections,  under  the 
same  conditions,  of  pus  from  the  abdomen  of  a  woman  who  had  died 
from  puerperal  infectious  disease,  f 

Relations  to  Zymotic  Diseases. — In  investigating,  some  years  ago, 
the  nature,  causes,  and  prevention  of  puerperal  fever,  J;  I  prepared, 
from  the  statistics  of  the  Health  Board  of  New  York  City,  tables  ex- 
tending over  a  period  of  nine  years,  to  answer  the  inquiry  as  to  whether 
there  was  any  relation  between  the  frequency  of  deaths  from  scarlatina, 
diphtheria,  and  erysipelas  and  those  from  metria.  Previous  to  their 
publication  I  was  anticipated  in  my  deductions  by  a  paper  upon  the 
same  subject,  by  Dr.  Matthews  Duncan.*  Neither  Duncan  nor  myself 
found  any  such  relation  existing  between  the  statistical  frequency  of 
puerperal  fever  and  the  zymotic  diseases  mentioned.  There  was, 
however,  nothing  in  our  investigations  to  invalidate  any  direct  testi- 
mony which  tends  to  show  that,  in  individual  cases,  a  real  connection 
between  puerperal  fever  and  the  zymotic  diseases  may  exist.  Indeed, 
it  seems  to  me  to  be  fairly  established  that  a  poison  may  be  conveyed 
from  patients  suffering  from  either  of  the  foregoing  morbid  processes, 
which  may  be  absorbed  by  the  puerperal  woman,  and  may  in  her  give 
rise  to  an  infectious  fever  possessing  an  intense  degree  of  virulence. 
The  close  relationship  between  erysipelas  and  puerperal  fever  is  some- 
times shown  by  the  occurrence,  in  the  latter,  of  an  erysipelatous 
inflammation,  extending  from  puerperal  vaginal  ulcers  over  the  cuta- 
neous surface  of  the  thigh  down  to  the  knee,  and  upward  over  the 
abdomen  to  the  waist.  That  in  these  cases  the  internal  process  is 
similar  in  character  is  a  fact  which  can  hardly  be  called  in  question. 

*  Braun,  "  Riickblicke  auf  die  Gesundbeits  Verhiiltnisse  unter  den  Wochnerinnen," 
u.  s.  w.,  pp.  32,  33. 

f  Haussmann,  '*  Untersuchungcn  und  Versuche  liber  die  Entstebung  dcr  ubcrtragbaren 
KranUheiten  dcs  Woebenbcttes,"  "Beitr.  zur  Geb.  und  Gynaek.,"  Bd.  iii,  Heft  3,  p.  314. 
X  "  Trans,  of  tbe  International  Med.  Congress,"  Philadelphia,  IS^G. 

*  Duncan,  "  On  the  Alleged  Occasional  Epidemic  Prevalence  of  Puerperal  Pyemia,  or 
Puerperal  Fever,  and  Erysipelas,"  "  Edinburgh  Med.  Jour.,"  March,  1876,  p.  774. 


PUERPERAL  FEVER. 


637 


Season  of  the  Year. — On  another  occasion  I  have  shown  that,  in 
Xew  York  City,  the  death-rate  from  puerperal  fever  is  nearly  twice  as 
great  during  the  six  months  from  December  to  May,  inclusive,  as 
from  June  to  ^^'ovember.  The  greatest  mortality  occurred  in  February 
and  March,  comprising  rather  more  than  one  fourth  the  entire  amount. 
The  smallest  number  of  deaths  occurred  in  September  and  October,  in 
which  months  but  one  thirteenth  of  the  entire  number  took  place. 

Social  State. — That  puerperal  fever,  in  its  harvest  of  death,  does 
not  spare  the  wealthy  and  well-to-do  classes  is  too  familiar  a  truth  to 
be  worthy  of  discussion.  That,  however,  the  wealthy  do  enjoy  s^iecial 
immunities  as  compared  with  the  less-favored  members  of  society  I 
have  shown  by  comparisons  made  between  sections  of  the  city  which, 
though  lying  side  by  side,  exhibit  in  a  marked  degree  the  two  extremes 
of  wealth  and  poverty.  Thus,  the  mortality  among  the  representatives 
of  the  lower  social  strata,  in  proportion  to  population,  was  from  three 
to  six  times  as  great  as  that  among  the  more  fortunate  classes. 

The  PREYENTioi^  OF  Puerperal  Fever. 

Of  the  3,342  deaths  from  puerperal  causes  in  New  York  City  from 
1868  to  1875,  inclusive,  420  occurred  in  hospital,  or  one  eighth  of  the 
entire  number.  Of  the  1,947  cases  of  metria,  about  300,  or  not  quite 
one  sixth,  were  contributed  by  the  hospitals.  After  such  a  showing, 
the  first  impulse  would  be  to  cry  out  loudly  for  the  suppression  of  the 
maternities.  But  a  wiser  policy  suggests  an  inquiry  as  to  whether  the 
large  mortality  mentioned  is  an  evil  necessity.  The  following  reports 
will  show  how  much  may  be  done,  in  the  present  state  of  our  scientific 
knowledge,  to  so  control  the  conditions  which  favor  the  generation  of 
puerperal  diseases  in  large  hospitals  as  to  make  them  safe  asylums  for 
the  needy. 

Dr.  Goodell*  has  stated  that,  at  the  Preston  Eetreat,  in  756  cases 
of  labor  there  have  been  but  two  deaths  from  septic  disease.  Winckel,f 
of  the  Lying-in  Institution  in  Dresden,  reported,  in  1873,  18  deaths 
from  metria,  or  1*8  per  cent.,  but,  from  the  10th  of  January  to  the 
7th  of  July,  in  570  births  there  was  but  one  case  of  septic  disease ;  in 
the  year  1872  the  death-rate  exceeded  5  per  cent.  The  reduction  in 
mortality  was  no  fortuitous  circumstance,  but  was  due  to  rigid  meas- 
ures for  the  prevention  of  disease.  Stadfeldt  |  reduced  the  mortality 
from  puerperal  fever  in  the  Maternity  Hospital  of  Copenhagen  from 
1  in  37,  the  proportion  between  the  years  1865  and  1869,  to  1  in  87 
between  the  years  18 70-' 74.    Dr.  Johnston  *  reports,  in  the  Rotunda 

*  GooDELL,  "  On  the  Means  employed  at  the  Preston  Retreat  for  the  Prevention  and 
Treatment  of  Puerperal  Diseases/'  p.  13. 

f  WiNCKEL,  "Beriehte  und  Studien,"  Leipsic,  18Y4,  p.  183. 

X  Stadfeldt,  "  Les  matemites,  leur  organisation  et  administration,"  Copenhagen,  1876. 

*  Johnston,  "  Clinical  Reports,"  from  1870  to  1876,  inclusive. 


638 


DISEASES  OF  CHILDBED. 


Hospital  of  Dublin,  during  the  seven  years  of  his  mastership,  7,860 
births,  with  169  deaths,  of  which  85,  or  1  in  91,  were  from  metria. 
Braun  von  Fernwald,*  in  sixteen  years,  reports  61,949  confinements 
in  the  vast  Maternity  Hospital  of  Vienna,  with  825  deaths  from  puer- 
peral fever,  or  1  -3  per  cent.  Spiegelberg  f  lost,  in  901  confinements  at 
Breslau,  only  five  cases  of  puerperal  fever.  Beurmann  J  reports  that 
in  the  Hopital  Lariboisiere,  under  the  administration  of  M.  Siredey, 
the  death-rate  in  1877  was  1  in  145,  and  in  1878  1  in  199  confine- 
ments ;  in  the  Hopital  Cochin,  under  the  charge  of  M.  Polaillon,  the 
total  mortality,  from  1873  to  1877,  was  1  to  108*7.  In  1877  there  was 
but  one  death  from  puerperal  causes  in  807  confinements. 

When  the  maternity  service  was  transferred,  in  1872,  from  Bellevue 
Hospital  to  Blackwell's  Island,  it  became  necessary  to  make  some  pro- 
vision for  so-called  street-cases — i.  e.,  women  taken  suddenly  in  labor 
without  homes,  and  representing  the  extremes  of  penury  and  want. 
At  first  they  were  received,  in  part,  by  the  various  private  institutions 
of  charity  in  New  York  City,  but  these,  in  1877,  decided  to  exclude 
them  thenceforth,  on  the  ground  that  their  condition  at  the  time  of 
their  reception  was  such  as  to  endanger  the  lives  of  the  inmates  for 
whom  the  charities  were  especially  provided.  An  old  engine-house 
was  then  put  in  readiness  by  the  city,  and,  under  the  name  of  the 
Emergency  Hospital,  was  placed  under  the  charge  of  Dr.  Henry  F. 
Walker  and  myself.  The  number  of  confinements  in  the  Emergency 
has  averaged  220  annually.  The  death-rate  from  all  causes  has  been 
two  per  cent.,  which,  though  large,  is  not  an  unfavorable  showing  when 
we  remember  that  the  patients  all  belong  to  the  homeless  class,  that 
all  were  taken  in  labor  before  their  entrance,  and  that  many  of  them 
were  in  a  deplorable  condition  at  the  time  of  their  admission.  The 
hospital,  too,  receives  a  considerable  number  of  patients  annually  who 
are  sent  there  only  after  protracted,  and  often  severe,  operative  meas- 
ures have  been  fruitlessly  attempted  outside  its  walls.  The  building 
possesses,  for  maternity  purposes,  two  fairly  ventilated  rooms.  Excel- 
lent nurses  are  furnished  by  the  New  York  Training  School  for  Nurses. 
Mr.  Osborn,  a  liberal  private  citizen,  has  had  constructed  in  the  rear, 
but  detached  from  the  main  house,  a  small  pavilion,  modeled  after 
that  of  Tarnier,  for  the  reception  of  infectious  cases.  The  Commis- 
sioners of  Charities  have  promptly  responded  to  every  call  made  upon 
them  to  extend  the  facilities  for  the  care  of  patients. 

Surely  these  results  do  not  support  the  idea  that  it  is  better  for  a 
woman  to  be  confined  in  a  street-gutter  than  to  enter  the  portals  of  a 
lying-in  asylum.    Dr.  Goodell's  experience  shows  that  a  hospital  for 

*  Braun  von  Fernwald,  "  Lehrbuch  dcr  gesammtcn  Gynaekologie,"  p.  885. 
f  Spiegelrerg,  "  Lehrbuch,"  p.  '748. 

X  Beurmann,  "  Recherches  sur  la  mortality  dcs  femmes  en  couches  dans  les  hopitaux," 
Paris,  1879. 


PUERPERAL  FEVER. 


639 


respectable  married  women  may  be  so  conducted  that  its  inmates  may 
enjoy  absolutely  a  greater  degree  of  safety  than  do  women  in  their 
homes,  surrounded  by  all  the  aids  that  wealth  can  command.  Equally 
good  results  are  not  to  be  obtained  in  hospitals  which  are  open  to  un- 
fortunates of  every  class.  But  there  is  much  misapprehension  and 
confusion  of  ideas  respecting  the  fate  of  these  women  when  no  chari- 
table provision  is  made  for  them.  In  Copenhagen  the  Maternity 
Hospital  is  closed  for  from  six  to  eight  weeks  in  the  summer-time. 
During  this  period,  unmarried  parturient  women  receive  pecuniary 
assistance  from  the  hospital  to  enable  them  to  obtain  a  place  in  which 
to  be  confined.  Now,  Stadfeldt  reports  a  larger  mortality  among  this 
class  than  among  those  delivered  in  the  hospital.  Yet  they  are  con- 
fined at  a  favorable  season  of  the  year,  without  any  communication 
with  the  furniture,  the  sage-femmes,  or  the  physicians  of  the  hospital. 
As  they  fortunately  receive  nothing  but  money,  that  can  hardly  be 
suspected  of  communicating  contagion.  What  their  fate  would  be  in 
New  York  City,  perhaps,  may  be  judged  from  the  following  facts  : 
Excluding  cases  confined  in  hospitals,  nearly  one  thirtieth  of  all  the 
deaths  and  one  twent3^-fourth  of  the  cases  of  metria  between  1867  and 
1875  are  reported  by  four  practitioners.  Ten  practitioners  out  of 
twelve  hundred  signed  the  death  certificates  of  one  fifteenth  of  the 
women  dying  from  puerperal  causes,  and  one  tenth  of  the  cases  of 
metria.  But  it  is  not  to  be  supposed  that  these  deaths  were  all  the 
result  of  malpractice  and  incompetence.  The  true  history  of  most  of 
them  probably  was  that  the  doctor  was  engaged  to  attend  the  case  of 
confinement  for  a  small  fee,  with  the  understanding  that  he  should 
make  no  calls  subsequently,  unless  specially  summoned  by  the  friends 
of  the  patient.  The  latter,  left  to  ignorant  care,  or  perhaps  without 
any  assistance  whatever,  and  exposed  to  all  the  pernicious  influences 
bred  by  poverty,  when  illness  supervened  probably  did  not  call  the 
physician  to  her  aid  until  the  time  for  help  had  passed,  so  that  in  the 
end  his  professional  functions  were  confined  to  procuring  the  requisite 
permit  for  burial. 

Humanity  demands  that  charity  should  furnish  places  of  refuge  in 
which  poor  outcasts  can  receive  assistance  during  the  perils  of  child- 
bearing.  If  we  must,  then,  have  maternities,  we  should  make  them 
safe,  and  this  can  be  in  great  measure  accomplished  by  remembering 
the  twofold  source  of  danger  arising  from  a  poisoned  atmosphere  and 
direct  inoculation.  A  hospital  must  be  clean,  spacious,  and  well 
ventilated,  or  its  atmosphere  will  become  charged  with  decomposing 
albuminoid  substances,  and  produce  nosocomial  malaria.  The  most 
rigid  sanitary  precautions  observed  by  the  attendants  will  not  prevent 
a  badly  ventilated  ward  from  becoming  unwholesome,  unless  unoccu- 
pied wards  are  kept  to  which  patients  can  be  transferred  upon  the  first 
admonition  of  danger.    Dr.  Goodell  states  that  at  the  Preston  Retreat 


640 


DISEASES  OF  CHILDBED. 


tlie  wards  are  used  invariably  in  rotation.  In  connection  with  the 
Maternity  at  Copenhagen  there  are  a  number  of  small  supplementary 
hospitals  scattered  through  the  city,  which  serve  as  safety-valves  for 
the  central  institution.  Artificial  methods  of  ventilation  render  the 
task  of  keeping  the  wards  wholesome  comparatively  easy.  They  do 
not  need,  however,  to  be  complicated  and  expensive.  The  good  re- 
pute of  the  Eotunda  Hospital,  it  seems  to  me,  is  in  large  measure  due 
to  the  natural  ventilation  afforded  by  open  fireplaces. 

In  the  Vienna  Clinic,  according  to  C.  Braun,  the  mortality  between 
1834  and  1862  averaged  six  per  cent. ,  and  in  1842  the  enormous  total  of 
521  deaths  to  3,067  confinements  was  reached.  With  the  introduction  in 
1862  of  what  is  known  as  Bohm's  heating  and  ventilation  system  an  im- 
mediate improvement  was  experienced.  In  the  sixteen  years  from  1863 
to  1878,  inclusive,  the  total  mortality  has  been  1*6  per  cent.,  though  in 
that  time  five  thousand  four  hundred  and  sixty-four  practitioners  have 
received  an  obstetrical  training  in  its  wards.  In  commenting  upon 
this  change  Braun  says:  *^I  have  now  from  practical  experience 
arrived  at  the  knowledge  of  the  fact  that  the  rapid  and  thorough  pre- 
vention of  putridity  by  adequate  ventilation  is  to  be  regarded  as  a 
good  preventive  measure  against  puerperal  fever ;  that  it  is  not  the 
number  of  patients  in  a  lying-in  hospital,  nor  yet  the  number  of  pa- 
tients in  a  single  room,  but  the  deficient  circulation  of  air,  a  fault 
which  may  inhere  to  separate  compartments  in  the  smallest  materni- 
ties, which  is  the  important  feature  in  the  spread  of  puerperal  fever  ; 
that  puerperal  women  are  to  be  protected  from  childbed  diseases  not 
by  isolated  buildings  and  gardens,  nor  by  walls,  but  by  the  permanent 
introduction  of  great  quantities  of  pure,  warm  air."  He  then  adds, 
what  is  in  thorough  accord  with  my  own  experience,  '^Before  new 
institutions  are  built,  greater  attention  than  heretofore  should  be  paid 
to  the  ventilation  of  the  old  structures,  and,  where  this  is  found  de- 
fective, a  system  should  be  substituted  corresponding  to  the  scientific 
requirements. " 

In  the  year  1872  puerperal  fever  destroyed  twenty-eight  women 
of  one  hundred  and  fifty-six  who  were  confined  in  the  Bellevue  Hospi- 
tal. The  service  was  then  broken  up,  and  a  great  outcry  arose  against 
tainted  hospitals."  Wooden  pavilions  were  accordingly  erected  on 
Blackwell's  Island  for  the  reception  of  lying-in  women.  These  build- 
ings were  constructed  upon  what  is  known  as  the  cottage  plan.  They 
were  favorably  situated  in  any  airy  location  remote  from  the  general 
hospital.  They  were,  however,  heated  by  large  iron  stoves,  and  no 
means  of  ventilating  the  wards  was  provided,  except  by  lowering  the 
windows.  In  less  than  three  months  from  their  occupancy  an  epi- 
demic of  puerperal  fever  made  it  necessary  to  remove  the  service  for  a 
time  to  tlie  Charity  Hospital.  The  same  result  followed  every  sub- 
sequent attempt  to  utilize  them  for  maternity  purposes,  until  after 


PUERPERAL  FEVER. 


641 


three  years'  trial  it  was  found  necessary  to  abandon  them  alto- 
gether. 

In  private  practice  it  is  likewise  important  that  the  lying-in  room 
should  be  provided  with  plenty  of  light  and  air.  The  physician 
should  insist  upon  the  value  of  ventilation  as  a  means  of  contributing 
to  the  speedy  recovery  of  childbed  women.  By  hermetically  sealing 
the  windows,  through  false  fears  of  his  patient's  taking  cold,  he  exposes 
her  to  the  risk,  of  becoming  poisoned  with  her  own  exhalations. 

But  the  early  experiences  of  the  Hopital  Cochin  and  the  Hopital 
Lariboisiere,  costly,  palace-like  structures,  with  every  appliance  of  art, 
prove  that  fresh  air  alone  does  not  protect  patients  from  the  conse- 
quences of  inoculation. 

The  great  improvement  in  the  condition  of  maternity  patients  in 
recent  yeai's  has  been  due  to  the  application  of  Lister's  principles  to 
obstetric  practice.  Complete  antisepsis  in  the  surgical  sense  is,  of 
course,  impracticable.  The  conduct  of  labor  under  carbolic  spray  has 
been  tried  in  Germany,  but  has  not  been  found  to  add  to  the  safety  of 
the  puerperal  woman.  Adequate  antisepsis  has,  however,  been  proved 
to  result  from  the  observance  of  a  variety  of  precautions  which  have 
been  the  slow  outcome  of  experience. 

These,  in  brief,  in  hospitals  consist  in  protecting  the  patient  from 
every  known  form  of  contamination,  and  in  the  prompt  removal  and 
isolation  of  every  puerperal  woman  who  manifests  febrile  symptoms. 

As  regards  details,  the  bedsteads  should  be  of  iron,  and  should  be 
frequently  scrubbed  with  a  carbolic  solution  ;  after  each  confinement 
the  palliasse  upon  which  the  woman  lay  should  be  washed  in  boiling 
water,  and  the  straw  should  be  burned  ;  in  place  of  the  usual  rubber 
covering  to  the  bed,  Tarnier  recommends  tarred  paper,  which  is  anti- 
septic, and  costs  so  little  that  it  need  be  used  in  but  a  single  case  ;  all 
soiled  linen  should  be  instantly  removed  from  the  ward,  either  to  be 
burned  or  disinfected  by  prolonged  boiling ;  sponges  should  be  ban- 
ished, as,  when  they  have  once  been  soaked  with  blood,  not  even  car- 
bolic acid  can  make  them  safe  ;  nurses  employed  in  the  puerperal 
wards  ought  not  to  have  access  to  cases  of  labor,  as  D'Espine  *  has 
shown  that  the  lochia  of  even  a  healthy  person  on  the  third  day  will 
poison  a  rabbit ;  a  patient  attacked  with  fever  should  be  immediately 
removed,  and  the  nurse  in  attendance  should  go  with  her. 

Doleris  f  formulates  the  indications  for  effective  prophylaxis  as 
follows  : 

1.  Prevent  the  introduction  of  germs  (antisepsis  before  confinement). 

2.  Paralyze  their  action  (antisepsis  after  confinement). 

3.  Shut  up  the  doors — veins,  lymphatics,  and  Fallopian  tubes  (em- 
ployment of  means  which  promote  uterine  contraction). 

*  D'Espine,  "  Contributions  h  I'etude  de  la  septicemic  puerperale,"  p.  18. 
t  Doleris,  "La  fievre  puerp6rale,"  1880,  p.  303. 
41 


642 


DISEASES  OF  CHILDBED. 


The  first  duty  of  the  physician  is  to  refrain  from  attending  a  case 
of  labor  when  fresh  from  the  presence  of  contagious  diseases,  or  from 
contact  with  septic  materials  whether  derived  from  the  dissecting- 
room  or  the  clinic.  Skepticism  regarding  these  sources  of  danger  is 
sure  in  the  long-run  to  be  severely  punished.  In  a  doubtful  case  the 
least  concession  should  consist  in  a  full  bath  and  a  complete  change  of 
clothing.  A  special  coat  for  confinement  purposes,  stained  with  blood 
and  amniotic  fluid,  is  liable  to  convey  infection.  In  every  case  of 
labor,  whether  in  hospital  or  private  practice,  the  hands  and  forearms 
should  be  freely  bathed  in  a  carbolic  solution  before  making  a  vaginal 
examination.  A  nail-brush  should  form  a  part  of  the  ordinary  ob- 
stetric equipment.  Frequent  examinations  during  labor  should  be 
avoided.  All  instruments  employed  during  or  subsequent  to  confine- 
ment should  be  carefully  disinfected.  In  prolonged  labors,  in  cases 
of  dystocia,  and  where  the  membranes  have  ruptured  and  the  foetus  is 
dead,  it  is  a  useful  precaution  after  delivery  to  wash  both  uterus  and 
vagina  with  warm,  carbolized  water.  In  hospitals  the  woman  should 
be  bathed  before  entering  the  lying-in  ward,  and  the  vagina  should  be 
disinfected  with  carbolic  acid  both  before  and  immediately  after 
labor. 

In  the  puerperal  period  the  warm  carbolized  douche  stimulates 
uterine  retraction  and  promotes  the  rapid  healing  of  wounds  in  the 
vaginal  canal ;  in  hospital  practice  it  possesses  the  additional  advan- 
tage of  preventing  the  accumulation  of  putrid  albuminoid  matters  in 
the  air.  In  private  practice  the  patient  should  employ  a  new  syr- 
inge ;  in  hospitals  every  woman  should  be  supplied  with  a  glass  tube 
to  be  attached  to  the  irrigator.  When  not  in  use  these  tubes  should 
be  immersed  in  carbolic  acid.  The  stream  injected  into  the  vagina 
should  be  continuous,  like  that  furnished  by  the  fountain  syringe. 
With  my  hospital  patients,  in  place  of  cloths  to  the  vulva,  I  have 
been  in  the  habit  of  using  oakum.  By  soaking  the  latter  in  a  solu- 
tion of  carbolic  acid,  the  vulva  is  surrounded  by  an  antiseptic  atmos- 
phere. 

Pedantic  as  these  directions  may  seem,  they  are  justified  by  experi- 
ence, and  the  carrying  out  of  the  details  given  easily  becomes  a  matter 
of  habit.  That  by  such  precautions  puerperal  fever  is  destined  to  be 
erased  from  the  list  of  dangerous  diseases  attacking  the  woman  in 
childbed  is  saying  more  than  is  warranted,  l^evertheless,  it  is  true 
that  a  physician  ought  never  to  lose  the  sense  of  personal  responsibility 
for  its  occurrence.  Indeed,  puerperal  fever  ought  to  be  regarded  as  a 
preventable  disease,  and  an  attack  as  the  evidence  that  some  source  of 
danger  has  been  overlooked,  though,  owing  to  the  imperfection  of 
our  knowledge,  it  may  easily  happen  that,  even  with  the  keenest  scru- 
tiny, the  precise  cause  in  an  individual  case  may  escape  detection. 


PUERPERAL  FEVER. 


643 


The  Treatment  of  Pueeperal  Fever. 

When  the  septic  germs  characteristic  of  putrid  infection  have  once 
entered  the  blood  thej  are  beyond  the  reach  of  the  physician.  Ex- 
cept, however,  in  cases  of  acute  septicaemia,  where  the  quantity  of 
poison  introduced  at  the  outset  is  excessive,  the  patient  rallies  from 
the  immediate  shock,  and,  provided  no  fresh  pyrogenic  material  finds 
its  way  into  the  system,  recovery  is  to  be  anticipated. 

The  indications  for  treatment  are,  therefore,  to  neutralize  the  puer- 
peral poison  at  the  point  of  production,  in  order  to  prevent  its  causing 
further  mischief,  and  to  adopt  measures  calculated  to  enable  the  pa- 
tient to  tolerate  its  presence,  when  once  absorbed,  until  it  is  either 
eliminated  or  loses  its  harmful  properties. 

Toward  the  fulfillment  of  the  first  indication  it  is  to  be  recom- 
mended that,  in  every  case  of  fever  of  puerperal  origin,  the  vagina  be 
cleansed  with  a  two-  to  three-per-cent.  solution  of  carbolic  acid  every 
four  to  six  hours.  The  douche  in  itself  is  absolutely  harmless.  In 
most  cases  the  infection  starts  from  the  wounds  of  the  vagina  and  of 
the  cervix.  Then,  too,  the  tendency  of  the  secretions  to  stagnate  in 
the  vaginal  cul-de-sac,  bathing  as  they  do  the  cervical  portion,  is  a 
prolific  source  of  septic  trouble.  In  all  but  the  mildest  cases  the  vagi- 
nal orifice  should  be  examined  with  reference  to  the  existence  of  puer- 
peral ulcers.  All  necrotic  patches  should  be  touched  with  hydrochloric 
acid,  with  a  ten-per-cent.  solution  of  carbolic  acid,  or,  what  I  person- 
ally prefer,  a  mixture  composed  of  equal  parts  of  the  solution  of  the 
persulphate  of  iron  and  the  compound  tincture  of  iodine.  The  latter 
acts  as  a  powerful  antiseptic,  while  the  former,  by  corrugating  the  tis- 
sues, closes  the  lymphatics  and  shuts  up  the  portals  through  which  the 
septic  germs  penetrate  into  the  system. 

Intra-uterine  injections  should  be  resorted  to  with  extreme  circum- 
spection. Unless  the  infection,  which  is  more  rarely  the  case,  pro- 
ceeds from  the  uterine  cavity,  they  are  unnecessary.  In  circumscribed 
inflammations,  where  the  morbific  poison  loses  its  virulence  at  a  short 
distance  from  the  puerperal  wound,  they  are  often  injurious.  I  make 
this  statement  as  an  unwilling  witness,  for  the  practice  of  local  disn- 
fection  is  in  accord  with  my  inmost  theoretical  convictions.  It  cer- 
tainly seems  rational  to  treat  the  uterus  as  one  would  any  other  pus- 
secreting  cavity.  The  procedure  is  warmly  advocated  by  Fritsch, 
Schiilein,  Kichter,  Langenbuch,  and  Schroeder,  as  a  prophylactic 
against  puerperal  affections.  C.  Braun,  however,  with  his  vast  oppor- 
tunities for  judging  obstetrical  questions,  writes,  with  reference  to 
this  :  "  We  must  protest  against  injections  made  by  physicians  into 
the  uterine  cavity.  Such  meddlesomeness  is  more  likely  to  do  harm 
than  good."  This  corresponds  with  my  own  experience.  Frequently, 
at  the  hospital,  I  have  had  occasion  to  witness  cases  where  the  patient's 


644 


DISEASES  OF  CHILDBED. 


condition  was  plainly  aggravated  by  injections  administered  with  un- 
tempered  zeal  by  members  of  the  house  staff.  Accidents,  such  as  con- 
vulsions, shock,  and  carbolic-acid  poisoning,  have  been  reported  by 
others. 

This  caution  is  not,  however,  intended  to  discourage  the  employ- 
ment of  intra-uterine  antisepsis  in  cases  where  it  is  strictly  indicated. 
Thus,  it  would  be  folly,  in  a  fever  due  to  the  decomposition  of  placen- 
tal debris,  of  shreds  of  decidua,  of  strips  of  membrane,  or  of  retained 
coagula,  or  in  diphtheritis  of  the  mucous  membrane,  to  treat  the  gen- 
eral symptoms,  and  neglect  the  local  cause  of  difficulty.  In  a  specific 
case  it  may  prove  difficult  to  decide  as  to  the  correct  course  to  pursue. 
In  general,  however,  it  may  be  stated  that  it  is  proper  to  wash  out  the 
entire  length  of  the  genital  canal  when  fever  follows  prolonged  opera- 
tions conducted  within  the  uterine  cavity,  or  the  birth  of  a  dead 
foetus  ;  and  in  cases  of  fever  associated  with  a  fetid  discharge  which 
persists  in  spite  of  the  vaginal  douche,  with  the  presence  of  recog- 
nizable portions  of  the  ovum  or  its  dependencies  in  the  lochia,  with 
the  repeated  discharge  of  decomposed  coagula,  or  with  a  large,  flabby 
uterus. 

The  operation  of  cleansing  the  uterus  should  be  conducted  with  the 
most  scrupulous  care.  The  syringe  employed  should  produce  a  con- 
tinuous and  not  an  interrupted  stream,  and  all  air  should  be  expelled 
from  the  pipe.  The  tube  to  be  passed  through  the  cervix  should  be 
of  glass,  of  the  size  of  the  little  finger,  and  bent  somewhat  to  conform 
to  the  pelvic  curve.  A  two-per-cent.  solution  of  carbolic  acid  should 
first  be  injected  into  the  vagina,  by  way  of  precaution  against  convey- 
ing septic  materials  into  the  uterus.  The  introduction  of  the  tube 
should  be  made  with  the  guidance  of  two  fingers  passed  through  the 
external  os.  But  slight  force  is  requisite  to  reach  the  ring  of  Bandl. 
It  is  neither  necessary  nor  desirable  to  push  the  tube  to  the  fundus. 
The  carbolized  fluid  injected  should  be  tepid,  and  of  the  strength  of 
two  to  three  drachms  to  the  pint.  It  should  be  introduced  very  slowly, 
and  pains  should  be  taken  to  insure  its  unimpeded  escape,  which  can 
usually  be  accomplished  by  pressing  the  anterior  wall  of  the  cervix 
forward  by  means  of  the  glass  tube.  Langenbuch  recommends  secur- 
ing permanent  drainage  by  leaving  a  bit  of  rubber  tubing  in  the  cer- 
vical canal,  a  plan  concerning  the  merits  of  which  I  am  not  able  to 
speak  from  experience.  The  tube  is  said  to  be  well  tolerated,  and  to 
possess  the  advantage  of  enabling  subsequent  injections  to  be  per- 
formed without  disturbing  the  patient. 

In  many  cases  the  results  of  intra-uterine  treatment  are  very  strik- 
ing. Often  the  temperature  falls  notably  within  an  hour  or  two  of 
the  operation.  This  result  is,  however,  rarely  permanent.  Usually 
the  fever  recurs,  and  the  operation  has  to  be  repeated.  The  patient 
should  be  carefully  watched,  and  with  the  first  sign  of  returning  dan- 


PUERPERAL  FEVER. 


645 


ger  the  injection  should  be  repeated.  Two  to  three  injections  may 
thus  be  called  for  in  twent3^-four  hours,  and  they  may  require  to  be 
continued  for  a  week.  Still  by  the  means  indicated  a  certain  pretty 
large  proportion  of  women,  seemingly  destined  to  destruction,  in  the 
end  make  favorable  recoveries. 
tk  Of  the  symptoms,  the  first  in  order  which  calls  for  treatment  is 
usually  the  peritoneal  pain.  It  is,  as  we  have  seen,  commonly  of  a 
lancinating  character,  and  is  associated  with  hurried  breathing  and 
extreme  frequency  of  the  pulse.  So  soon  as  the  pain  is  once  fairly 
under  control,  the  violence  of  the  onset  begins  to  abate.  It  should  be 
met,  therefore,  by  the  hypodermic  injection  of  from  one  sixth  to  one 
third  grain  of  morphia  in  solution.  The  anodyne  action  should  be 
maintained  by  doses  administered  by  the  mouth  in  quantities  and  at 
intervals  suited  to  the  severity  of  the  case.  The  most  important  ob- 
ject to  be  secured  is  freedom  from  spontaneous  pain.  It  is,  moreover, 
good  practice  to  push  the  opiate  until  pain  elicited  by  pressure  is  like- 
wise controlled,  provided  it  can  be  accomplished  without  producing 
narcosis.  In  susceptible  patients,  and  in  localized  inflammations,  the 
quantity  required  may  not  be  very  great,  while  in  acute  general  peri- 
tonitis the  tolerance  of  the  drug  exhibited  by  puerperal  women  is 
sometimes  extraordinary.  Thus,  a  patient  of  Professor  Alonzo  Clark 
took  the  equivalent  of  934  grains  of  opium  in  four  days  ;  a  patient  of 
Professor  Fordyce  Barker  13,969  drops  of  Magendie's  solution  in  eleven 
days  ;  and  one  of  my  own,  at  the  Maternity,  the  equivalent  of  over 
1,700  grains  of  opium  in  seven  days.*  In  this  latter  instance  the  pa- 
tient was  to  all  appearance  moribund  when  the  treatment  was  begun. 
Thus,  the  features  were  pinched,  the  face  was  drawn,  the  pupils  were 
dilated,  the  finger-tips  were  blue  and  cold,  the  respirations  were  rapid, 
and  the  pulse  was  scarcely  perceptible.  In  this  condition  the  large 
doses  of  opium  did  not  produce  narcosis,  but  were  followed  by  restora- 
tion of  the  circulation,  by  normal  breathing,  and  by  the  disappearance 
of  the  symptoms  of  shock.  Any  attempt  to  relax  the  treatment  was 
at  once  succeeded  by  a  recurrence  of  the  alarming  symptoms.  At  the 
expiration  of  the  disease  the  opium  was  discontinued  abruptly  without 
detriment  to  the  patient. 

In  contrast  to  cases  of  acute  peritonitis,  an  extreme  susceptibility 
to  opium  is  often  observed  in  the  pysemic  variety.  Here  opiates  seem 
to  me  rarely  to  do  good.  They  do  not  hinder  the  migrations  of  the 
round  bacteria,  there  is  rarely  pain  to  relieve,  and  I  have  sometimes 
thought  that  their  administration  was  simply  the  addition  of  a  sec- 
ond poison  to  the  one  which  already  was  overwhelming  the  nervous 
system. 

In  pelvic  peritonitis,  in  the  course  of  forty-eight  hours  plastic  exu- 

*  The  details  of  this  case  have  been  reported  in  the  "  Am.  Jour,  of  Obst.,"  Oct.,  1880, 
p.  864,  by  Dr.  F.  M.  Welles,  who  conducted  the  administration  of  the  opium. 


646 


DISEASES  OF  CHILDBED. 


dation  is  thrown  out  and  the  pain  to  a  great  extent  subsides.  From 
this  time  very  moderate  doses  of  opium,  as  a  rule,  are  needed  to  make 
the  patient  comfortable. 

In  France,  leeches  applied  to  the  abdomen  are  much  used  as  a 
means  of  relieving  peritoneal  sensitiveness.  That  they  do  this  is  be- 
yond question.  Their  disuse  in  this  country  is  due  probably  more  to 
popular  prejudice  than  to  their  inefficacy. 

In  the  beginning  of  an  attack  a  turpentine  stupe  to  the  abdomen  is 
a  source  of  comfort  to  many  women,  while  the  sharp  counter-irritation 
exercises  possibly  a  favorable  influence  upon  the  course  of  the  disease. 
At  a  later  period  I  commonly  employ  flannels  wrung  out  in  water,  and 
covered  with  oil-silk  to  prevent  speedy  evaporation.  It  is  an  old  expe- 
rience that,  in  the  beginning  of  a  puerperal  fever,  the  provocation  of 
loose  stools  by  purgatives  is  frequently  followed  by  a  fall  in  the  tem- 
perature and  a  great  improvement  in  the  patient's  condition.  The 
result,  however,  is  far  from  uniform,  as  in  other  cases  these  artificial 
diarrhoeas  have  a  tendency  to  aggravate  the  peritoneal  symptoms. 
Owing  to  this  uncertainty  in  their  action,  purgative  remedies  should 
be  administered  with  caution,  not  from  any  theory  as  to  their  elimina- 
tive  powers,  but  because  of  the  ascertained  existence  of  fecal  accumu- 
lation. In  pelvic  inflammations,  castor-oil  in  two  to  three  tablespoon- 
ful  doses,  or  five  to  ten  grains  of  calomel  rubbed  up  with  twenty  grains 
of  bicarbonate  of  sodium,  as  recommended  by  Professor  Barker,  may 
be  given  when  thus  indicated.  After  the  bowels  have  once  been  freed, 
however,  the  purgative  should  not  be  repeated.  In  cases  of  intense 
local  inflammation,  and  in  general  peritonitis,  enemata  should  alone 
be  employed  for  the  removal  of  constipation. 

Every  increase  of  body-heat  is  associated  with  rapid  tissue-waste, 
with  enfeebled  heart-action,  and  with  exhaustion  of  the  nerve-centers. 
Since  the  modern  recognition  of  the  deleterious  effects  of  high  tem- 
peratures per  se,  antipyretic  remedies  in  place  of  the  old-time  cardiac 
sedatives  have  come  to  play  the  leading  role  in  the  treatment  of  fevers. 

Of  internal  antipyretic  agents  quinine  enjoys  a  deservedly  high  re- 
pute. In  the  remitting  forms  of  fever  it  may  be  administered  in  five- 
grain  doses  at  intervals  of  four  to  six  hours.  Given  thus  in  medium 
doses  it  moderates  the  fever,  diminishes  the  sweating,  and  in  most 
patients  lessens  gastric  and  intestinal  disturbances.  In  continued 
fevers  it  should,  on  the  contrary,  be  given  in  a  single  dose  large  enough 
to  procure  a  distinct  remission.  By  making  a  break  in  the  febrile 
symptoms,  if  only  of  a  few  hours'  duration,  a  retardation  of  the  de- 
structive processes  is  accomplished.  At  the  first  administration,  twen- 
ty to  thirty  grains  may  be  given.  In  favorable  cases  the  temperature 
falls  in  the  course  of  a  few  hours  below  101°.  When  the  high  tem- 
perature is  only  temporarily  held  in  check,  at  the  end  of  twenty-four 
hours,  if  all  symptoms  of  cinchonism  have  disappeared,  the  same  dose 


PUERPERAL  FEVER. 


647 


should  be  repeated.  If  the  doses  mentioned,  given  in  the  manner 
prescribed,  produce  no  perceptible  effect  upon  the  fever,  their  continu- 
ance may  be  regarded  as  unnecessary. 

C.  Braun  and  Eichter  speak  favorably  of  the  action  of  salicylate 
of  sodium.  *  It  possesses  antipyretic  properties,  though  in  a  less  degree 
than  quinine.  It  is,  however,  rapidly  absorbed,  circulates  through  all 
the  parenchymatous  organs,  and  finally  is  discharged  unchanged  in 
the  urine.  It  is  said  by  Binz,  in  small  doses,  to  hinder  the  action  of 
the  disease — producing  ferments,  while  it  leaves  untouched  the  normal 
ferments  of  the  organism.  It  is  of  sj)ecial  service  where  quinine  is  not 
well  tolerated,  or  when  given  fifteen  to  twenty  grains  at  a  time  every 
four  to  six  hours  as  an  adjuvant  to  large  single  doses  of  quinine.  The 
remedy  should  be  continued  until  all  traces  of  febrile  disturbance  have 
disappeared. 

A  more  powerful  remedy  than  salicylic  acid,  where  quinine  has 
failed,  is  the  Warburg's  tincture.  Some  patients  find,  however,  that 
it  is  somewhat  difficult  to  retain  upon  the  stomach. 

'Not  many  years  ago,  owing  to  the  encomiums  of  Professor  Fordyce 
Barker,  f  the  tincture  of  veratrum  viride  was  in  great  favor  in  puer- 
peral fever  as  a  means  of  reducing  the  excited  pulse  of  inflammation. 
The  plan  recommended  was  to  administer  five  drops  hourly,  in  con- 
junction usually  with  morphia,  until  the  pulse  was  brought  down  to 
70  or  80  beats  to  the  minute.  If  the  pulse  had  once  been  reduced,  then 
three,  two,  or  one  drop  hourly  would  be  found  sufficient  to  control  it. 
V omiting  and  collapse  from  its  use  were  no  cause  for  alarm,  as  they 
were  temporary  symptoms,  and  were  followed  by  a  fall  of  the  pulse  to 
30  or  40  a  minute,  which  was  rather  of  favorable  prognostic  signifi- 
cance. In  the  rapid  pulse  of  exhaustion,  however,  veratrum  should 
not  be  given.  Since  the  introduction  of  the  thermometer  into  prac- 
tice, the  reduction  of  the  pulse  by  veratrum  has  been  found  to  be  asso- 
ciated with  a  fall  in  the  temperature  of  the  body.  Of  late,  however, 
veratrum  has  gone  rather  out  of  vogue,  not  because  it  is  not  a  very 
effective  agent,  but  because  its  administration  is  an  art  to  be  ac- 
quired, and  can  not  safely  be  intrusted  to  an  unskilled  assistant. 
Then,  too,  in  the  last  ten  years,  there  has  grown  up  a  better  acquaint- 
ance with  less  dangerous  remedies. 

Braun  recommends  in  severe  cases,  where  quinine  alone  is  without 
effect,  to  give  in  addition  from  twelve  to  twenty-four  grains  of  digi- 
talis in  infusion  per  diem  until  its  specific  action  is  produced.  Unlike 
veratrum,  digitalis  effects  a  permanent  slowing  of  the  heart.  By  pro- 
longing the  cardiac  diastole  and  contracting  the  arterioles,  it  allows 
the  left  ventricle  to  fill,  restores  the  arterial  tension,  diminishes  cor- 

*  RiCHTER,  "Ueber  intrauterine  Injectionen,"  etc.,  "Ztschr.  fiir  Geburtsh.  und  Gy- 
naek.,"  Bd.  ii,  Heft  1,  p.  146. 

f  F.  Barker,  "  The  Puerperal  Diseases,"  p.  347. 


648 


DISEASES  OF  CHILDBED. 


respondingly  the  intra-venous  pressure,  and  promotes  absorption.  Its 
tendency  to  produce  gastric  disturbances  and  the  distrust  felt  as  to 
its  safety  have  prevented  its  becoming  popular  in  practice. 

Alcohol  as  an  adjuvant  to  treatment  is  indicated  in  all  cases, 
whether  quinine,  or  salicylic  acid,  or  veratrum  be  simultaneously  em- 
ployed. It  stimulates  and  sustains  the  heart,  it  retards  tissue-waste, 
and  is  in  itself  an  antipyretic  of  no  mean  value.  Usually  I  give  it  in 
conjunction  with  quinine,  one  or  two  teaspoonfuls  hourly  of  either 
whisky,  rum,  or  brandy,  in  accordance  with  the  recommendation  of 
Breisky.*  But  many  years  before  I  had  learned  from  my  friend  Pro- 
fessor Barker  that  the  specific  influence  of  veratrum  was  in  many 
cases  not  obtained  until  the  use  of  alcohol  was  combined  with  it. 

The  antipyretic  action  of  drugs  is  probably  due  for  the  most  part 
to  some  direct  influence  they  exert  upon  the  oxygenation  of  the  tis- 
sues. Of  course,  the  less  the  fire  the  less  the  heat.  It  is  well,  how- 
ever, to  support  their  internal  administration  by  the  external  employ- 
ment of  cold.  Cold  owes  its  effect  in  fevers  partly  to  the  abstraction 
of  heat  from  the  body-surface,  and  in  a  still  more  important  degree 
to  the  impression  which  it  produces  upon  the  nervous  system. 

In  healthy  persons  the  action  of  cold  is  to  increase  the  consump- 
tion of  oxygen  and  the  production  of  carbonic  acid.  The  additional 
heat  thus  generated  renders  it  possible  to  sustain  the  vicissitudes  of 
climate.  In  fevers  the  primary  effect  of  cold  is  similar  in  character. 
Its  main  therapeutical  action  is  derived  from  its  secondary  influence 
upon  the  nerve-center  which  regulates  the  body-heat.  If  the  cold 
employed  be  sufficiently  intense  or  sufficiently  prolonged,  there  fol- 
lows, not  always  immediately,  but  in  the  course  of  an  hour  or  two,  a 
marked  lowering  of  the  temperature,  which  can  only  be  accounted 
for  by  assuming  an  indirect  influence  exerted  through  the  sympathetic 
nerve  and  the  medulla  oblongata.  This  peculiarity  renders  the  exter- 
nal application  of  cold  a  most  valuable  addition  to  the  therapeutical 
resources  available  in  fevers. 

In  cases  of  moderate  severity,  frequently  sponging  the  patient  with 
cold  water  will  be  found  to  be  a  grateful  practice.  An  ice-cap  to  the 
head,  where  the  blood  lies  near  the  surface,  will  often  affect  the  en- 
tire temperature  of  the  body.  From  immemorial  times  it  has  been 
employed  to  control  delirium  and  promote  sleep.  An  ice-bag  placed 
over  the  inguinal  region  is  locally  beneficial  to  deep-seated  pelvic 
inflammations,  and,  according  to  0.  Braun,  is  capable  of  effecting  a 
rapid  fall  of  temperature.    Ice-cold  drinks  should  be  freely  allowed. 

Schroeder  recommends  a  permanent  stream  of  cold  water  in  the 
uterine  cavity  by  means  of  a  large  irrigator  and  a  drainage-tube  ;  oth- 
ers advise  cold  rectal  injections  maintained  for  long  periods  with  the 
aid  of  a  tube  with  a  double  current. 

*  Breisky,  "Ueber  Alcohol  und  Chinin-bchandlung,"  Bern,  1875. 


PUERPERAL  FEVER. 


649 


In  fevers  of  great  violence,  the  systematic  application  of  cold  by 
means  of  baths  or  the  wet-pack  is  capable  in  some  cases  of  rendering 
important  service.  The  temperature  of  the  bath  should  range  from 
70°  to  80°.  Its  duration  should  not  exceed  ten  minutes.  The  pa- 
tient should,  when  removed  to  the  bed,  be  wrapped  in  a  sheet  with- 
out drying,  and  should  be  comfortably  covered.  In  employing  the 
wet-pack,  tAvo  beds  should  be  placed  side  by  side.  The  body  and 
thighs  of  the  patient  should  be  wrapped  in  a  sheet  wrung  out  in  cold 
water,  and  be  allowed  to  remain  in  the  pack  from  ten  to  twenty  min- 
utes. As  the  sheet  becomes  heated  the  patient  should  be  placed  in  a 
fresh  one  upon  the  second  bed,  and  the  transfers  should  be  continued 
until  the  desired  fall  of  temperature  is  effected.  Braun  claims  that 
four  packs  are  equivalent  in  action  to  one  full  bath. 

Both  these  methods  are,  however,  open  to  the  objection  that  they 
can  not  be  carried  out  without  considerable  disturbance  of  the  pa- 
tient, a  point  of  no  small  importance  in  cases  of  peritonitis.  Dr.  G. 
B.  Kibbie  has  invented  a  fever-cot  which  obviates  the  ordinary  diffi- 
culties of  this  mode  of  treatment.  The  cot  is  covered  with  a  strong, 
elastic  cotton  netting,  manufactured  for  the  purpose,  through  which 
water  readily  passes  to  the  bottom  below,  which  is  of  rubber  cloth  so 
adjusted  as  to  convey  it  to  a  vessel  at  the  foot."  Professor  T.  G. 
Thomas,*  who  has  employed  this  apparatus  extensively  to  reduce  high 
temperatures  after  ovariotomies,  explains  as  follows  the  modus  ope- 
randi : 

Upon  this  cot  a  folded  blanket  is  laid,  so  as  to  protect  the  patient's  body 
from  cuttiag  by  the  cords  of  the  netting,  and  at  one  end  is  placed  a  pillow  cov- 
ered with  India-rubber  cloth,  and  a  folded  sheet  is  laid  across  the  middle  of  the 
cot  about  two  thirds  of  its  extent.  Upon  this  the  patient  is  now  laid,  her  cloth- 
ing is  lifted  up  to  the  armpits,  and  the  body  enveloped  by  the  folded  sheet, 
which  extends  from  the  axillae  to  a  little  below  the  trochanters.  The  legs  are 
covered  by  flannel  drawers  and  the  feet  by  warm  woolen  stockings,  and  against 
the  soles  of  the  latter  hottles  of  warm  water  are  placed.  Two  blankets  are  then 
placed  over  her,  and  the  application  of  water  is  made.  Turning  the  blankets 
down  below  the  pelvis,  the  physician  now  takes  a  large  pitcher  of  water,  at 
from  75°  to  80°,  and  pours  it  gently  over  the  sheet.  This  it  saturates,  and  then, 
percolating  the  network,  it  is  caught  by  the  India-rubber  apron  beneath,  and, 
running  down  the  gutter  formed  by  this,  is  received  in  a  tub  placed  at  its  ex- 
tremity for  that  purpose.  Water  at  higher  or  lower  degrees  of  heat  than  this 
may  be  used.  As  a  rule,  it  is  better  to  begin  with  a  high  temperature,  85°,  or 
even  90°,  and  gradually  diminish  it. 

The  patient  now  lies  in  a  thoroughly  soaked  sheet,  with  warm  bottles  to 
her  feet,  and  is  covered  up  carefully  with  dry  blankets.  Neither  the  portion  of 
the  thorax  above  the  shoulders  nor  the  inferior  extremities  are  wet  at  all.  The 
water  is  api)lied  only  to  the  trunk.  The  first  effect  of  the  affusion  is  often  to 
elevate  the  temperature,  a  fact  noticed  by  Currie  himself;  but  the  next  affusion, 

*  Thomas,  "  The  Most  Effectual  Method  of  controlling  the  High  Temperature  occur- 
ring after  Ovariotomy,"  "  N.  Y.  Med.  Jour.,"  August,  1878. 


650 


DISEASES  OF  CHILDBED. 


practiced  at  the  end  of  an  hour,  pretty  surely  brings  it  down.  It  is  better  to 
pour  water  at  a  moderate  degree  of  coldness  over  the  surface  for  ten  or  tifteen 
minutes,  than  to  pour  a  colder  fluid  for  a  shorter  time.  The  water  slowly 
poured  robs  the  body  of  heat  more  surely  than  when  used  in  the  other  way. 
The  water  collected  in  the  tub  at  the  foot  of  the  bed,  having  passed  over  the 
body,  is  usually  8°  or  10°  warmer  than  it  was  when  poured  from  the  pitcher. 
On  one  occasion  Dr.  Van  Yorst,  my  assistant,  tells  me  that  it  had  gained  12°. 

At  the  end  of  every  hour  the  result  of  the  affusion  is  tested  by  the  ther- 
mometer, and  if  the  temperature  has  not  fallen  another  affusion  is  practiced,  and 
this  is  kept  up  until  the  temperature  comes  down  to  100°,  or  even  less. 

It  must  be  appreciated  that  the  patient  lies  constantly  in  a  cold  wet  sheet ; 
but  this  never  becomes  a  fomentation,  for  the  reason  that,  as  soon  as  it  abstracts 
from  the  body  sufficient  heat  to  do  so,  it  is  again  wet  with  cold  water  and  goes 
on  still  with  its  work  of  heat-abstraction.  I  have  kept  patients  upon  this  cot 
enveloped  in  the  wet  sheet  for  two  and  three  weeks,  without  discomfort  to  them 
and  with  the  most  marked  control  over  the  degree  of  animal  heat.  Ordinarily, 
after  the  temperature  has  come  down  to  99°  or  100°,  four  or  five  hours  will  pass 
before  affusion  again  becomes  necessary. 

Since  reading  this  account,  I  have  made  a  good  many  trials  of  the 
method  upon  puerperal  women,  and  have  not  found  that  it  agrees  with 
all  in  an  equal  degree.  In  some  instances  the  affusions  have  been  fol- 
lowed, in  spite  of  hot  bottles  to  the  feet  and  the  administration  of 
stimulants,  by  such  a  degree  of  depression  and  impairment  of  cardiac 
force,  as  shown  by  the  persistent  coldness  of  the  extremities,  that  it 
has  been  necessary  to  discontinue  them.  On  the  other  hand,  I  can 
look  back  upon  cases  apparently  so  desperate  that  the  condition  of  the 
patients  was  looked  upon  as  hopeless,  where  they  proved  the  means  of 
saving  life  as  by  a  miracle.  Of  course,  the  difference  depends  upon 
whether  the  high  temperature  is  the  sole  cause  of  the  alarming  symp- 
toms, or  whether  the  latter  are  in  part  due  to  blood  dissolution  and 
secondary  changes  in  the  parenchymatous  organs. 

It  is  hardly  necessary  to  state  that,  in  puerperal,  as  in  other  fevers, 
the  patient's  strength  requires  to  be  sustained,  and  the  waste  of  tissue 
to  be  repaired,  as  far  as  possible,  by  the  regulated  administration  of 
liquid  food,  as  milk  and  beef -tea,  in  such  quantities  as  can  be  borne 
by  the  stomach,  and  at  one  to  two  hours  intervals. 

In  the  treatment  of  encysted  peritoneal  effusions,  and  in  inflamma- 
tory exudations  into  the  pelvic  and  adjacent  cellular  tissue,  after  the 
acute  symptoms  have  subsided,  the  attention  should  be  directed  to  the 
afternoon  fever,  and  to  promoting  the  assimilation  of  food.  So  soon 
as  the  sweating  and  fever  are  checked,  the  absorption  of  the  plastic 
materials  begins.  The  most  important  agents  for  accomplishing  this 
object  are  quinine,  in  moderate  doses,  combined  with  some  form  of 
alcohol  and  with  tepid  sponging.  Deep-seated  pain  in  the  iliac  region 
is  best  relieved  by  a  large  blister  upon  the  side,  over  the  point  where 
the  tenderness  is  felt.   Prolonged  rest  in  bed  should  be  enjoined.  Even 


PUERPERAL  FEVER. 


651 


after  conyalescence  is  well  advanced,  so  long  as  the  exudation  remains 
unabsorbed,  the  resumption  of  household  duties  is  pretty  certain  to  be 
followed  by  a  relapse  or  by  the  development  of  a  chronic  condition  of 
a  most  intractable  description.  The  sooner  the  patient's  stomach  can 
be  got  to  digest  and  absorb  beefsteak  and  iron,  the  more  speedy  will 
be  her  recovery. 

In  pelvic  exudations  the  hot  vaginal  douche,  warm  baths,  and 
the  application  of  flannels  wrung  out  in  water  to  the  abdomen  aid  in 
diminishing  the  local  pain  and,  perhaps,  in  causing  a  disappearance 
of  the  tumor.  The  action  of  mercurials  or  of  iodide  of  potassium  in 
melting  away  plastic  inflammatory  materials  is  sometimes  very  strik- 
ing, but  more  frequently  they  either  do  no  good,  or  else  do  harm  by 
disturbing  the  digestion. 

If  fever,  chills,  and  sweating  announce  the  presence  of  pus,  the 
most  careful  exploration  should  be  made  to  determine,  if  possible,  the 
seat  of  suppuration.  It  is  of  great  advantage  to  treat  pelvic  abscesses 
as  abscesses  are  treated  elsewhere  in  the  body.  If  the  redness  of  the 
skin  above  Poupart's  ligament  indicates  a  tendency  to  point  in  that 
direction,  an  aspirator-needle  should  be  introduced  to  make  sure  of 
the  diagnosis.  If  the  sac  is  near  the  surface,  a  free  incision  should 
be  made,  and  the  pus  should  be  allowed  to  escape.  In  many  cases 
I  make  these  incisions  three  to  four  inches  in  length.  The  red- 
ness of  the  external  skin  makes  it  certain  that  the  abscess  has  be- 
come adherent  to  the  abdominal  wall,  and  that  the  incision  con- 
sequently will  not  communicate  with  the  peritonaeum.  After  the 
abscess  has  been  opened,  it  should  be  cleansed  twice  daily,  and  the 
cavity  should  be  filled  with  oakum.  If  after  a  time  the  granula- 
tions become  flabby,  Peruvian  balsam  should  be  poured  into  the  sac 
at  each  change  of  the  dressing.  I  can  recommend  this  plan  as  essen- 
tially a  mild  procedure.  With  a  large  opening  for  the  discharge  of 
pus,  the  fever  and  sweating  disappear,  the  appetite  returns,  and  the 
abscess  fills  rapidly  by  granulation.  With  a  small  incision,  hectic  is 
apt  to  persist,  and  the  abscess  to  end  in  the  formation  of  intermina- 
ble fistulae. 

If  softening  and  bagginess,  or  distinct  fluctuation,  indicate  that  the 
pus  can  be  reached  through  the  vaginal  cul-de-sac,  the  aspirator-needle 
should  be  inserted  deeply  at  the  suspected  point,  and,  if  a  large  amount 
of  pus  is  detected,  an  incision  should  be  made  with  a  long-handled 
bistoury,  using  the  needle  as  a  director,  and  making  the  opening  large 
enough  to  permit  the  introduction  of  a  self -retaining  Nelaton  catheter. 
The  latter  is  easily  passed  by  means  of  a  uterine  sound  inserted  into 
the  eye  at  the  extremity.  Through  the  catheter,  without  disturbing 
the  patient,  the  pus-cavity  can  be  washed  as  frequently  as  required, 
and,  with  drainage  and  cleanliness,  cases  of  the  longest  standing  may 
be  expected  to  recover. 


652 


DISEASES  OF  CHILDBED. 


Dr.  P.  F.  Munde  *  has  reported  a  number  of  cases  of  chronic  char- 
acter where  the  aspiration  of  pus  has  been  followed  by  rapid  absorp- 
tion of  the  intra-pelvic  exudation.  The  presence  of  pus  was  suspected 
because  of  a  boggy,  doughy  feeling  in  the  exudation  tumor. 


CHAPTER  XXXVII. 

PUERPERAL  INSANITY.— PHLEGMASIA  ALBA  DOLENS.— DISEASES  OF 

THE  BREASTS. 

The  insanity  of  pregnancy,  of  childbed,  of  lactation. — Phlegmasia  alba  dolens. — Defective 
milk  secretion. — Galactorrhoea. — Sore  nipples. — Subcutaneous  inflammation  of  the 
breast. — Submammary  abscess. — Parenchymatous  mastitis. — Galactocele. 

The  Insanity  of  Pregkancy,  Childbed,  and  Lactation. 

When  we  remember  the  marked  perturbation  of  the  nervous  sys- 
tem, in  even  normal  pregnancy,  from  reflex  causes,  from  disorders  of 
the  digestion,  and  from  depravation  of  the  blood,  it  is  not  strange 
that  the  same  conditions  which  give  rise  to  moral  perverseness,  to 
the  loss  of  memory,  to  hysteria,  or  to  hypochondria,  should  likewise 
prepare  the  way  for  the  outbreak  of  the  more  pronounced  forms  of 
mental  derangement.  In  character  the  psychical  disturbances  of 
child-bearing  women  do  not  differ  from  those  which  develop  under 
ordinary  circumstances,  but  so  active  are  the  causes  during  the  period 
in  question  that,  of  the  insane  who  crowd  the  public  asylums,  in  one 
eighth,  according  to  Tuke,  the  malady  is  of  puerperal  origin.  In 
many  women  there  exists  in  advance  an  hereditary  disposition  to 
insanity,  the  events  of  pregnancy  and  childbed,  which  are  commonly 
associated  with  the  ultimate  attack,  acting  simply  as  the  sparks  which 
fire  the  mine. 

During  pregnancy  the  prevailing  form  of  mental  disturbance  is 
melancholia,  with  sometimes  a  tendency  to  suicide.  The  prognosis  is 
favorable  when  the  disease  develops  in  the  early  months  and  follows 
physiological  depression  and  hypochondria ;  unfavorable  in  severe  at- 
tacks occurring  first  in  the  latter  half  of  pregnancy,  or  where  preg- 
nancy intervenes  in  the  case  of  insanity  previously  existing.  As  a  rule, 
these  patients  can  be  best  cared  for  in  well-regulated  private  insti- 
tutions, where  they  are  not  subjected  to  the  good-intcntioned  expos- 
tulations of  intimate  friends. 

The  pains  of  labor  in  excitable  persons  are  said  to  give  rise  at  times 
to  a  transitory  delirium,  but  this  certainly  is  of  very  rare  occurrence 

*  MuNDE,  "  Diagnosis  and  Treatment  of  Obscure  Pelvic  Abscess,"  etc.,  "  Arch,  of 
Med.,"  December,  18S0. 


PUERPERAL  INSANITY. 


653 


in  these  days  of  anaesthetics.  The  indications  for  treatment  are,  of 
course,  to  relieve  the  pain,  and  to  hasten  the  birth  of  the  child. 

Mania  may  occur  in  any  severe  puerperal  affection.  It  has  been 
observed  not  only  in  the  various  forms  of  metritis,  but  even,  accord- 
ing to  Winckel,  as  a  result  of  sore  nipples  and  very  painful  inflam- 
mations of  the  breasts.  The  delirium  in  these  cases  rises  and  falls 
with  the  fluctuations  in  the  underlying  malady,  and  is  thought  to  be 
dependent  upon  associated  cerebral  hyperaemia.  The  maniacal  mani- 
festations may  consist,  when  there  is  freedom  from  suffering,  of  agree- 
able hallucinations — the  patient  often  singing  or  wearing  on  her  face 
a  rapt  expression  ;  or,  if  the  pain  is  great,  she  may  on  the  other  hand 
see  forms  which  threaten  her,  so  that  in  terror  she  cries  for  help, 
springs  from  bed,  and  strips  off  her  clothes  in  the  effort  to  escape  the 
source  of  danger.  The  prognosis  depends,  of  course,  upon  the  gravity 
of  the  morbid  condition  of  which  the  mania  is  only  a  symptom.  The 
treatment,  with  the  exception  of  dry  cold  to  the  head,  is  that  of  the 
main  affection. 

Again,  puerperal  mania  may  proceed  from  an  hereditary  predispo- 
sition or  from  diseases  antedating  pregnancy,  in  either  case  the  puer- 
peral state  acting  as  the  proximate  but  not  as  the  fundamental  cause 
of  the  outbreak.  The  attacks  may  be  accompanied  by  erotomania,  by 
nymphomania,  by  religious  anxiety,  or  by  the  cUlire  de  persecution. 
It  may  be  evoked  by  psychical  impressions.  It  occurs  at  an  early 
period  of  childbed,  when  the  strength  is  wasted  by  pain,  excitement, 
or  fever. 

Finally,  puerperal  mania  may  be  caused  by  exhausting  losses  of 
blood,  by  intense  pain,  by  eclampsia,  or  by  anything  which  occasions 
cerebral  congestion.  In  this,  the  so-called  idiopathic  form  of  puerperal 
mania,  the  attack  is  generally  preceded  by  sleeplessness,  indistinctness 
of  speech,  by  restless  movement^,  and  the  refusal  to  take  food.  At 
the  beginning  of  the  attack  the  delirium  is  usually  of  a  noisy  charac- 
ter, the  patients  screaming,  praying,  or  preaching  in  a  declamatory 
fashion  ;  or  they  try  to  get  out  of  bed  and  to  escape  from  the  room  by 
the  doors  or  windows.  Sexual  excitement  is  rare,  the  disposition  to 
strip  off  the  night-dress  and  expose  the  person  proceeding  not  from 
an  erotic  impulse,  but  from  a  desire  to  escape  from  some  fancied 
restraint.  Attempts  to  control  these  patients  by  force  are  apt  to  excite 
them  to  renewed  violence.  This  acute  stage  is  followed  by  melancho- 
lia, characterized  by  weeping,  praying,  and  fears  concerning  the  com- 
mission of  the  unpardonable  sin.  As  a  result  of  the  mental  depression, 
suicidal  tendencies  develop  in  a  considerable  proportion  of  the  cases. 
The  period  at  which  the  outbreak  first  attracts  notice  occurs  most  fre- 
quently within  the  first  two  weeks. 

The  indications  for  treatment  are  to  check  profuse,  exhausting  dis- 
charges, to  support  the  patient's  strength,  and  to  insure  perfect  quiet. 


654 


DISEASES  OF  CHILDBED. 


With  the  first  sign  of  trouble  the  child  should  be  taken  from  the  breast, 
liquid  food  should  be  given  at  frequent  intervals,  care  should  be  taken 
to  keep  the  bladder  and  the  rectum  empty,  the  room  should  be  dark- 
ened, and  its  temperature  should  be  regulated.  The  activity  of  the 
skin  should  be  promoted  by  means  of  the  sponge-bath.  The  sacrum 
should  be  watched  and  strapped  with  adhesive  plaster  if  bed-sores 
threaten.  Furniture,  pictures,  or  any  articles  which  disturb  the  pa- 
tient should  be  removed  from  her  sight.  There  is  no  condition  in 
which  trained  nursing  can  do  so  much  toward  effecting  recovery.  The 
nurse's  duties  are  to  administer  food,  to  see  that  urination  is  regularly 
performed,  to  keep  the  patient  covered,  and  to  prevent  her  from  doing 
harm  to  herself  or  others.  Members  of  the  household  who  can  not 
resist  the  impulse  to  show  the  insane  woman  the  folly  of  her  delusions 
should  be  regarded  as  disqualified  from  entering  the  sick-room.  Pas- 
toral visits  are  rarely  beneficial.  If  the  patient  becomes  violent,  it  is 
usually  possible  for  the  family  physician  to  obtain  obedience  without 
tlie  exercise  of  restraint  or  force.  So  important  is  the  question  of 
personal  influence  in  the  management  of  puerperal  insanity  that  the 
success  of  home  treatment  is  almost  wholly  dependent  upon  the  control 
which  the  physician  has  acquired  over  the  morale  of  his  patient  previ- 
ous to  the  occurrence  of  her  malady.  Narcotics  do  not  cure,  but  when 
they  produce  a  few  hours  sleep  they  certainly  promote  recovery.  There 
is  hardly  one  in  the  entire  list  which  has  not,  at  some  time,  done  me 
good  service.  My  preference  is  for  chloral  and  the  bromide  of  potas- 
sium (aa  gr.  xxx)  in  solution,  and  administered  by  the  rectum.  To 
procure  an  effect  from  moderate  doses  it  is,  however,  necessary  that 
the  narcotic  be  given,  not  during  the  period  when  the  patient  is  most 
voluble  and  restless,  but  either  after  she  has  become  quieted  by  judi- 
cious management  or  during  a  natural  interval  of  calm.  Cold  to  the 
head  is  often  very  effective  in  relieving  headache  and  cerebral  conges- 
tion. If  the  stage  of  exaltation  passes  into  that  of  melancholia,  the 
question  of  continued  home-treatment  becomes  a  serious  one.  The 
mother  sometimes  exhibits  not  only  indifference,  but  even  a  positive 
dislike,  to  her  child,  which  makes  it  a  risky  thing  to  leave  them  alone 
together.  Again,  owing  to  the  suicidal  tendencies  which  often  go 
with  melancholia,  it  never  is  safe  to  allow  the  patient  to  pass  out  of 
observation,  as  is  shown  by  the  following  case  :  A  young  woman  after 
her  first  confinement  had  an  attack  of  mania  for  which  she  was  sent 
to  a  private  asylum.  Shortly  after,  she  was  removed  by  her  friends 
to  her  own  home.  There  her  sweetness  and  passive  resignation  dis- 
armed suspicion.  One  day,  however,  she  dropped  her  sewing,  put  on 
her  hat,  and,  bidding  her  mother  a  pleasant  good-by,  walked  quietly 
down  to  the  river — a  half-mile  away — and  composedly  laid  doAvn  in 
the  shallow  stream  near  the  bank,  so  that  the  water  covered  her  face. 
From  this  position  she  was  rescued  by  some  men  who  were  mowing  in 


PHLEGMASIA  ALBA  DOLENS. 


655 


a  field  near  by,  and  by  them  was  carried  insensible  to  her  home.  The 
next  day  she  was  returned  to  the  asylum,  where  she  soon  made  a  good 
recovery. 

The  insanity  of  lactation  is  either  the  result  of  cerebral  anaemia  or 
a  relapse  from  a  previous  attack.  It  begins,  as  a  rule,  six  to  ten 
weeks  after  confinement.  In  most  cases  it  assumes  the  form  of  melan- 
cholia. The  prognosis  is  good  if  the  disease  is  treated  in  season,  by 
stopping  lactation  and  by  removing  the  debility  upon  which  it  depends. 

In  general,  the  prognosis  of  puerperal  mania  is  favorable,  more  than 
sixty  per  cent,  of  the  cases  ending  in  recovery.  In  private  practice 
the  number  is  probably  much  larger.  During  convalescence  care 
should  be  taken  to  secure  to  the  patient  rest,  sleep,  nutritious  food, 
and  a  daily  evacuation  of  the  bowels,  and  little  by  little  she  should  be 
brought  back  once  more  to  old  habits  and  the  responsibilities  of  exist- 
ence. 

Phlegmasia  Alba  Dolens. 

Phlegmasia  alba  dolens  is  the  term  applied  to  a  swelling  of  one  or 
both  lower  extremities,  occurring  usually  between  the  tenth  and  twen- 
tieth day  after  confinement,  and  characterized  by  pain,  tension  of  the 
skin,  and  a  milk-like  whiteness  of  the  surface.  Owing  to  its  color 
and  its  supposed  origin,  it  has  received  the  popular  name  of  milk-leg. 
Phlegmasia  is  an  affection  of  the  connective  tissue,  and  is  associated  in 
most,  but  not  in  all,  cases  with  thrombosis  of  the  veins. 

The  origin  of  the  swelling  is  somewhat  obscure.  In  a  certain  pro- 
portion of  cases  phlegmasia  is  obviously  the  extension  of  an  inflamma- 
tory process  from  the  genital  organs  to  the  perinseum,  the  nates,  and 
the  upper  portion  of  the  thigh.  If  confined  to  the  subcutaneous  and 
intermusculai  cellular  tissue,  the  vessels  may  not  become  affected. 
When,  however,  the  morbid  changes  follow  the  sheaths  of  the  vessels, 
the  walls  of  both  veins  and  lymphatics  thicken,  and  in  most  cases 
secondary  thrombus  formation  results. 

In  other  instances  the  thrombus  formation  is  apparently  the  pri- 
mary lesion.  It  may  occur  spontaneously  from  slowing  of  the  blood- 
current.  A  predisposition  to  thrombosis  is  created  by  varicose  veins. 
The  vessels  usually  involved  are  the  crural  and  its  branches,  the  tibial 
and  peroneal  veins.  Again,  the  intra-venous  coagula  may  start  from 
the  placental  site,  and,  extending  along  the  pampiniform  plexus  to  the 
hypogastric  vein,  may  thence  occlude  the  crural  to  Poupart's  ligament, 
or,  passing  upward  by  the  spermatic  veins,  they  may  obstruct  the  vena 
cava.  Sometimes  the  occlusion  of  one  crural  vein  is  succeeded  by  that 
of  the  other,  phlegmasia  in  that  case  developing  in  both  extremities. 

Thrombus  formation  may  begin  during  pregnancy,  and  is  then 
usually  attended  with  pain  at  the  seat  of  trouble,  and  with  stiffness  in 
the  toes  or  the  dorsum  of  the  foot.  As  a  rule,  however,  the  disease  is 
rare  before  the  second  week  following  labor.    Often  it  is  preceded  by 


656 


DISEASES  OF  CHILDBED. 


gastric  disturbances,  as  lack  of  appetite,  a  furred  tongue,  and  consti- 
pation, by  chilly  sensations,  and  by  a  heavy  feeling  in  the  affected 
limb.  A  careful  examination  sometimes  reveals  the  existence  of  in- 
flamed or  thrombosed  veins  in  the  leg,  in  the  popliteal  space,  or  upon 
the  inner  surface  of  the  upper  i^ortion  of  the  thigh.  If  the  affected 
veins  are  superficial,  the  redness  and  swelling  may  be  obvious  to  the 
eye. 

The  first  characteristic  symptom  is  the  development  in  the  limb  of 
a  dull,  dragging  pain,  which  is  increased  by  motion.  Tenderness  to 
pressure  is  only  experienced  along  the  course  of  inflamed  vessels. 

In  primary  thrombosis  the  swelling  usually  begins  at  the  ankle,  and 
spreads  rapidly  to  the  knee  and  upward  to  the  inguinal  region ;  in 
secondary  thrombosis,  extending  from  the  uterine  sinuses,  and  in  the 
superficial  form  of  phlegmasia,  the  swelling,  on  the  contrary,  travels 
commonly  in  the  reverse  direction,  viz.,  from  the  inguinal  fold  to  the 
ankle. 

The  onset  may  or  may  not  be  announced  by  a  chill.  Fever  often 
precedes  and  accompanies  the  attack.  It  is,  however,  in  uncomplicated 
cases,  of  a  mild  type,  and  sinks  to  the  normal  point  long  before  the 
swelling  of  the  limb  subsides.  Severe  chills  and  intense  fever,  with 
marked  remissions,  are  symptomatic  of  metastatic  pyaemia.  Other  com- 
plications may  essentially  modify  the  course  of  the  disease.  The  pain, 
the  tenderness,  and  the  febrile  disturbance  are  usually  greatest  in 
the  phlegmonous  form  of  swelling,  which  starts  from  the  genital 
organs. 

The  ordinary  termination  of  phlegmasia  is  by  absorption  of  the 
thrombus,  with  restoration  of  the  circulation.  As  this  takes  place, 
the  tension  of  the  skin  subsides,  and  the  parts  pit  upon  pressure,  as  in 
ordinary  oedema.  As  the  swelling  and  pain  subside,  the  mobility  of  the 
limb  becomes  restored.  The  period  of  extreme  tension  lasts,  as  a  rule, 
for  from  five  to  eight  days.  Recovery  takes  place  slowly,  the  dis- 
persion of  the  tumor  requiring  from  three  to  six  weeks. 

A  less  common  result  consists  in  the  permanent  obliteration  of  the 
vessel  by  the  conversion  of  the  thrombus  into  a  solid  connective-tissue 
cord,  in  which  case  the  extremity  may  long  continue  heavy  and  loco- 
motion be  attended  with  difficulty. 

In  rare  instances  the  process  may  terminate  in  suppuration  and 
abscess  formation.  The  prognosis  of  a  pus  collection  in  the  vicinity 
of  a  vessel,  resulting  from  periphlebitis,  is  usually  favorable,  the  symp- 
toms that  it  occasions  disappearing  when  the  abscess  is  opened  and 
the  pus  is  allowed  to  escape.  When  the  suppurative  process  is  of  a 
spreading  character,  undermining  the  skin  and  attacking  the  inter- 
muscular cellular  tissue,  the  destructive  changes  may  assume  frightful 
proportions.  Thus,  in  hospital  practice,  we  sometimes  witness  cases 
where  the  muscles  are  dissected  from  one  another  and  are  bathed  in 


DISEASES  OF  THE  BREAST. 


657 


an  ichorous  fluid,  with  greenish  particles  of  necrosed  tissue  adhering 
to  them,  death  ensuing  from  intense  septicaemia. 

Sometimes  a  thrombus  becomes  infected  and  undergoes  puriform 
softening,  with  detachment  of  small  particles,  which,  entering  the  cir- 
culation, give  rise  to  infarctions  and  metastatic  abscesses  ;  or  a  large 
fragment  may  be  separated  accidentally  from  a  normal  clot,  and,  pass- 
ing by  the  yena  caya  and  the  right  side  of  the  heart,  may  cause  sudden 
death  by  plugging  the  pulmonary  artery. 

The  prognosis,  from  what  has  been  said,  is  eyidently  dependent 
upon  the  origin  of  the  phlegmasia  and  upon  the  nature  of  the  com- 
plications. The  principal  indications  for  treatment  are,  opium  to  al- 
leyiate  pain,  cathartics,  if  needed,  to  unload  the  bowels,  quinine,  iron, 
and  good  food  to  sustain  the  strength,  and  rest  for  the  swollen  ex- 
tremity. The  latter  should  be  raised  somewhat  higher  than  the  body, 
and  during  the  early  stages  of  the  swelling  should  be  wrapped,  as  rec- 
ommended by  Dr.  F.  Barker,  in  cotton-batting  and  oil-silk.  The  tender- 
ness should  be  mitigated  by  the  application  of  soothing  liniments.  If 
yesicles  form  upon  the  surface  they  should  be  punctured  and  the  fluid 
be  allowed  to  escape.  When  the  extremity  begins  to  pit  on  pressure 
and  the  tenderness  to  subside,  absorption  should  be  promoted  by 
gentle  frictions  with  alcoholic  lotions  and  by  bandaging  the  entire 
limb  eyenly  with  a  flannel  roller.  Until  every  trace  of  tenderness  and 
thickening  has  disappeared  from  the  yeins,  the  patient  should  under 
no  circumstances  be  allowed  to  leaye  her  bed.  The  danger  of  death 
from  sudden  obstruction  of  the  pulmonary  artery  is  always  present 
until  the  thrombus  has  disappeared  or  become  firmly  organized. 

For  some  time  after  recovery  has  taken  place  the  limb  will  swell  as 
the  result  of  standing  or  of  protracted  exercise,  a  condition  which,  as 
a  rule,  is  greatly  benefited  by  the  patient  wearing  a  long  elastic  stock- 
ing. 

Diseases  of  the  Breast. 

Defective  Milk- Secretion. — A  scanty  milk-secretion  due  to  lack  of 
mammary  deyelopment,  to  extreme  youth,  to  polysarcia,  or  to  the 
mature  age  of  the  mother,  is  not  amenable  to  treatment.  Temporary 
insufficiency,  resulting  from  defectiye  nutrition,  may  sometimes  be 
remedied  by  a  regulated  nitrogenized  diet,  by  the  tincture  of  iron,  an 
out-door  life,  and  by  the  consumption  of  large  quantities  of  fluid.  A 
diet  composed  for  the  most  part  of  milk  is  strongly  to  be  recom- 
mended. If  the  baby  is  feeble,  and  sleeps  or  cries  when  put  to  the 
breast,  it  is  a  good  plan  for  the  mother  to  borrow  for  a  time  a  healthy 
infant  with  strong  suction-powers  to  stimulate  the  glands  to  perform 
their  functions.  Cataplasms  of  castor-oil  leaves  or  fennel-teas  possess 
no  claims  to  confidence. 

GalactorrhoBa. — An  abundance  of  milk  is  not  pathological,  the 
quantity  quickly  accommodating  itself  to  the  wants  of  the  child.  A 

42 


«58 


DISEASES  OF  CHILDBED. 


constant  dribbling  of  milk  from  the  nipple,  or  galadorrhcea,  an  affec- 
tion which  may  continue  long  after  lactation  has  been  suspended,  acts, 
like  any  other  profuse  discharge,  in  exhausting  the  strength  and  in 
producing  a  wasting  of  the  tissues.  The  treatment  consists  in  inter- 
rupting lactation,  in  compression  of  the  breasts,  and  in  the  employ- 
ment of  such  dietetic  measures  as  are  best  calculated  to  repair  the 
general  health  ;  of  special  measures,  saline  laxatives  and  the  internal 
administration  of  iodide  of  potassium  are  of  most  repute. 

Sore  Nipples. — Under  the  term  sore  nipples  are  included  a  number 
of  lesions  which,  in  spite  of  their  seeming  triviality,  possess  consider- 
able importance,  not  only  on  account  of  the  suffering  they  occasion, 
but  because  they  furnish  the  starting-point  of  most  cases  of  mammary 
abscess. 

A  simple  erythema,  associated  with  great  tenderness,  is  a  common 
trouble  at  the  beginning  of  lactation,  to  which,  however,  primiparag 
are  more  subject  than  multiparse.  It  is  a  good  plan  to  anticipate  this 
difficulty  by  instructing  the  patient  to  wash  the  nipples  daily,  during 
the  last  weeks  of  pregnancy,  with  some  astringent  or  alcoholic  solu- 
tion. In  childbed,  in  addition  to  strict  cleanliness,  great  benefit  is 
derived  from  folding  a  linen  rag  around  the  nipple  and  keeping.it  con- 
stantly wetted  with  Goulard's  extract,  a  teaspoonful  to  a  tumbler  of 
water,  until  the  sensitiveness  and  redness  have  disappeared.  Before 
applying  the  child  to  the  breast,  care  should  be  taken  to  wash  away 
the  deposited  carbonate  of  lead. 

In  many  women,  owing  to  the  maceration  and  loosening  of  the 
epithelium  from  the  oozing  of  the  colostrum,  suckling  of  the  child  is 
followed  by  the  formation  of  small  vesicles,  which  eventually  rupture 
and  produce  isolated  erosions.  Under  favorable  conditions,  these  ero- 
sions become  covered  with  crusts  beneath  which  the  healing  process 
takes  place.  If,  however,  the  crusts  are  removed  by  suckling  before  a 
new  layer  of  epithelium  has  had  time  to  form,  the  simple  excoriation 
may  be  converted  into  an  ulceration  with  deep  destruction  of  tissue. 
If  the  child  be  suffering  from  sprue,  the  transfer  of  the  oidium  albicans 
may  impart  to  the  wounds  of  the  nipple  an  aphthous  character.  If  the 
primary  vesicles,  in  place  of  remaining  isolated,  coalesce,  the  nipple 
may  become  bared  of  its  epithelium  over  a  considerable  extent  of  its 
surface.  The  papillae  then  enlarge  and  give  a  raspberry-like  appear- 
ance to  the  exposed  structure. 

Fissures  of  the  nipples  are  excruciatingly  painful,  and  are  capable 
of  exciting  even  a  high  degree  of  fever.  They  occur  with  greatest  fre- 
quency in  nipples  which  have  been  flattened  by  the  pressure  of  corsets, 
or  in  which  the  natural  fissures  between  the  papillae  are  of  unusual 
depth.  Most  commonly  they  are  seated  at  the  base  of  the  organ. 
Either  they  may  develop  from  the  erosions  just  described,  or  the  clefts 
upon  the  surface  may  become  covered  by  crusts  composed  of  dirt  and 


DISEASES  OF  THE  BREAST. 


659 


colostrum,  which,  when  torn  away  by  the  nursing  child,  detach  the 
delicate  underlying  epithelium. 

As  regards  the  treatment,  it  is  well  to  bear  in  mind  that,  with 
cleanliness  and  the  removal  of  irritatirg  matters  from  the  wounded 
surface,  the  worst  cases  of  sore  nipples  will  get  well  in  from  twenty- 
four  to  forty-eight  hours,  provided  lactation  is  suspended.  The  object 
of  treatment,  therefore,  is,  to  cure  the  lesion  without  interfering  with 
the  nursing  of  the  child.  This  is  comparatively  easy  when  but  one 
nipple  is  affected,  as  the  child  need  only  be  applied  to  the  sound 
side.  In  that  case,  however,  the  excessive  tension  which  results  from 
the  suspension  of  lactation  should  be  relieved  by  stroking  the  breast 
from  the  base  toward  the  apex  with  the  hands,  or  by  getting  the  nurse 
to  draw  the  milk  with  her  mouth,  or  by  means  of  a  breast-pump  with 
a  wide,  trumpet-shaped  extremity.  The  healing  process  can  at  the 
same  time  be  promoted  by  lead-lotions,  by  a  solution  of  tannin,  or  by 
some  astringent  ointments.  My  rule  is  to  keep  upon  the  nipple  a  rag 
wetted  with  the  Goulard's  extract,  as  described  for  erythema,  during 
the  patient's  waking  hours,  substituting  therefor  a  carbolized  oint- 
ment during  the  hours  of  sleep,  when  the  drying  of  a  lotion  would 
cause  the  rag  to  adhere  to  the  raw  surface.  If  the  child  be  troubled 
with  sprue,  special  attention  must  be  taken  to  cure  its  mouth,  and 
the  development  of  the  oidium  albicans  upon  the  nipple  should  be 
prevented  by  frequent  washings  with  solutions  of  boracic  acid  or  of 
the  sulphite  of  sodium. 

Cracks  are  much  more  rebellious  to  treatment  than  simple  erosions. 
If  of  any  extent,  the  nipple  should  be  drawn  to  one  side,  so  as  to  expose 
the  fissure,  which  should  be  touched  with  the  point  of  the  mitigated 
stick  of  nitrate  of  silver.  As  the  effect  of  the  latter  is  intended  to  be 
local,  it  should  be  applied  dry,  the  lymph  furnished  by  the  denuded 
surface  affording  the  requisite  moisture.  I  mention  this  trivial  detail, 
*as,  in  hospital  practice,  I  have  sometimes  seen  the  entire  nipple  robbed 
of  its  epithelium,  owing  to  the  mistake  made  by  the  house-physician 
of  first  dipping  the  pencil  in  water,  and  then  allowing  the  strong  solu- 
tion to  diffuse  itself  over  the  sensitive  surface.  The  compound  tinct- 
ure of  benzoin,  strongly  recommended  by  Professor  F.  Barker,  makes 
a  good  stimulating  application  to  cracks  of  the  nipple.  Though 
somewhat  painful  when  used  for  the  first  time,  it  is  afterward  easily 
tolerated. 

If  both  nipples  are  simultaneously  affected,  lactation  can  not,  of 
course,  be  entirely  interrupted  without  drying  up  the  milk,  but  the 
intervals  between  the  acts  of  nursing  should  be  lengthened  as  much  as 
the  comfort  of  the  mother  will  permit.  If  the  milk  will  not  come 
without  tugging,  the  flow  should  be  furthered,  before  applying  the 
child,  by  stroking  the  breasts.  Of  nipple-shields  I  am  not  able  to 
speak  with  much  enthusiasm.    Many,  if  not  most,  infants  resent  the 


660 


DISEASES  OF  CHILDBED. 


ordinary  rubber  ones,  and  refuse  to  suck  through  them.  A  more 
acceptable  form  is  one  provided  with  a  rubber  tube  and  mouth-piece, 
such  as  commonly  goes  with  nursing-bottles,  but  it  is  apt  to  drive 
away  the  milk  if  its  use  is  long  persisted  in.  Legroux  recommends  a 
bit  of  gold-beater's  skin,  fastened  to  the  breast  by  means  of  collodion, 
and  perforated  with  a  needle  over  the  portion  which  covers  the  open- 
ings of  the  lactiferous  ducts.  But,  even  without  these  aids,  in  time  a 
cure  can  usually  be  effected  by  perseverance  in  the  use  of  the  remedies 
already  mentioned.  It  is  necessary  to  stop  nursing  altogether  only 
when  the  nipples  are  hopelessly  flat  and  misshapen,  or  when  mastitis 
threatens. 

For  eczema,  lead,  zinc,  or  white-precipitate  ointment  may  be  em- 
ployed. In  obstinate  cases  a  solution  of  corrosive  sublimate  (gr.  v  ad 
I  j)  is  recommended  by  Hebra. 

Subcutaneous  Inflammation  of  the  Breasts. — The  subcutaneous  in- 
flammation may  be  confined  to  the  areola,  which  then  becomes  red, 
swollen,  and  excessively  sensitive.  This  form  generally  terminates  in 
suppuration,  and  may  form  fistulous  communications  with  the  lactif- 
erous ducts.  Sometimes  the  inflammation  begins  in  the  sebaceous 
follicles,  giving  rise  to  small  boils  around  the  nipple. 

In  other  cases  inflammation  may  extend  beyond  the  areola,  and 
either  give  rise  to  localized  abscesses,  or,  when  due  to  the  septic  infec- 
tion of  excoriated  nipples,  assume  an  erysipelatous  character. 

The  treatment  of  both  these  forms  consists  in  the  application  of 
warm  lead-lotions,  and  in  the  early  evacuation  of  the  pus.  To  avoid 
cutting  into  the  milk-ducts,  the  incision  should  radiate  from  the 
nipple. 

Inflammation  of  the  Submammary  Connective  Tissue. — This  rare 
condition  owes  its  origin,  according  to  Billroth,  in  most,  if  not  in  all, 
cases  to  abscess  formation  in  the  deep-lying  glandular  structures,  the 
pus  perforating  the  fascia-like  connective  tissue  at  the  base  of  the  organ 
into  the  loose  connective  tissue  situated  between  the  gland  and  the 
pectoral  muscle.  The  breast  is  in  consequence  lifted  from  the  trunk, 
and  can  be  moved  to  and  fro  as  though  it  rested  upon  a  water-bed. 
The  skin  is  not  reddened,  but  is  sometimes  markedly  oedematous.  The 
pain  is  deep-seated  and  dull ;  the  fever  is  high  and  continuous ;  the 
axillary  glands  swell,  and  movements  of  the  arm  are  hindered  by  the 
increase  of  the  pain  they  occasion.  Stoltz  is  said  to  have  removed 
from  such  a  sac  twenty  ounces  of  pus.  So  soon  as  the  pus-formation 
is  recognized,  a  free  incision  should  be  made  at  the  lower  portion  of  the 
gland,  and  the  wound  should  be  treated  with  the  antiseptic  precautions 
which  will  be  given  in  connection  with  parenchymatous  mastitis. 

Parenchymatous  Mastitis. — Inflammation  of  the  glandular  struct- 
ures of  the  breast  develops  usually  in  the  first  four  weeks  after  confine- 
ment.   It  is  characterized  by  pain,  high  fever,  and  nodular  enlarge- 


DISEASES  OF  THE  BREAST. 


661 


ment  of  the  affected  lobules.  The  attack  usually  begins  with  a  sharp 
chill.  These  symptoms  are  sometimes  observed  three  to  four  days 
after  the  birth  of  the  child,  at  the  beginning  of  lactation,  but  then  are 
usually  temporary,  the  commencing  mastitis  terminating  in  sponta- 
neous resolution.  Mastitis  leading  to  abscess-formation  belongs,  for 
the  most  part,  to  a  later  period,  occurring  most  frequently  in  the  third 
or  fourth  week,  long  after  the  first  inflammatory  symptoms  have  sub- 
sided. 

Puerperal  mastitis  is  quite  commonly  t)elieved  to  be  due  to  emo- 
tional causes,  to  cold,  to  blows,  or  to  caking"  from  milk  retention 
— all  suppositions  of  extreme  convenience  as  relieving  the  physician 
from  responsibility  for  their  occurrence.  They  certainly,  however, 
play  a  subordinate  role  in  the  etiology  of  the  affection,  the  lesions  of 
the  nipples  furnishing,  with  perhaps  rare  exceptions,  the  starting-point 
from  which  the  inflammation  travels  to  the  glands,  either  passing  to 
the  deep-seated  tissues  by  the  lymphatics,  or  following  the  track  of 
the  lactiferous  ducts  to  the  glandular  acini.  The  exact  anatomical 
structure  of  the  resulting  nodular  masses  is,  for  the  most  part,  matter 
of  conjecture.  Only  this  much  is  known  certainly,  that  they  are 
composed  in  part  of  glandular  structures  and  in  part  of  the  swollen 
interstitial  tissue  ;  that  the  lactiferous  ducts  are  either  constricted  or 
closed  ;  that  suppuration  takes  place  both  in  the  connective  tissue  and 
in  the  acini ;  and  that  the  large  abscess-cavities  form  from  the  coales- 
cence of  small  pus-collections.  The  walls  of  the  abscess  are,  therefore, 
never  smooth,  but  are  uneven,  with  projecting  portions  of  glandular 
tissue  which  has,  as  yet,  not  undergone  disintegration.  The  milk- 
secretion  is  arrested  in  the  affected  lobules.  If,  as  sometimes  happens, 
a  large  duct  is  perforated,  pus  may  be  discharged  with  the  milk,  or,  in 
case  the  abscess  opens  externally,  a  milk-fistula  may  be  produced. 
When  several  foci  of  inflammation  exist,  they  may  suppurate  in  suc- 
cession, so  that  abscess  after  abscess  may  develop,  and  the  morbid 
condition  be  protracted  for  weeks,  and  even  months.  If  the  abscesses 
break  spontaneously,  at  a  point  unfavorable  for"  the  discharge  of  pus, 
fistulous  passages  are  liable  to  be  produced.  In  hospitals,  as  the  result 
of  long-continued  suppuration  and  necrosis  of  tissue,  entire  lobes  may 
undergo  destruction,  with  subsequent  cicatricial  formation  and  ensu- 
ing deformity  of  the  breast ;  or,  with  the  access  of  unwholesome  air  to 
the  abscess-cavities,  the  sloughing  tissues  may  become  gangrenous  and 
death  may  follow  from  septicaemia. 

The  first  important  point  as  regards  the  treatment  of  parenchyma- 
tous mastitis  is  to  take  the  child  from  the  breast.  If  this  is  done 
early,  in  a  very  large  number  of  cases  the  inflammation  will  disappear 
without  advancing  to  suppuration.  If  lactation  is  continued,  espe- 
cially when  sore  nipples  persist  as  a  complication,  the  chances  of 
avoiding  abscess -formation  are  extremely  small.    In  cases  of  pain  due 


662 


DISEASES  OF  CHILDBED. 


to  excessive  fullness  of  the  milk-ducts,  partial  relief  should  be  given  by 
means  of  mammary  expression.  For  the  pain,  opium,  for  the  fever, 
a  full  dose  of  quinine,  should  be  administered.  A  saline  cathartic  acts 
as  a  derivative  and  diminishes  the  hyperaemia  of  the  breasts.  As  the 
pain  of  the  inflammation  is  augmented  by  the  weight  of  the  organ, 
the  breast  should  be  raised  and  supported  by  a  suitable  bandage. 
Much  comfort  is  often  afforded  by  the  local  application  of  belladonna, 
in  the  form  either  of  an  ointment,  or  of  the  liniment  diluted  with 
three  or  four  parts  of  opodeldoc.  Considerable  relief  is  likewise  ob- 
tained by  laying  a  flannel  wetted  with  a  lead-and-opium  wash  over 
the  breast,  and  placing  on  the  outside  some  water-proof  substance  to 
prevent  speedy  evaporation.  A  large  flaxseed-poultice  lessens  pain 
by  reason  of  its  heat,  but  should  not  be  employed,  at  least  so  long  as 
the  hope  of  absorption  has  not  been  abandoned. 

So  soon  as  there  are  evidences  of  pus,  such  as  bogginess,  oedema, 
or  reddening  of  the  skin,  the  abscess  should  be  opened  with  antisep- 
tic precautions.  If  the  inflamed  acini  are  situated  near  the  surface, 
fluctuation  is  early  apparent.  In  deep-seated  abscesses,  the  precise 
situation  of  the  pus  collections  is  not  easy  to  determine.  If  the 
matter  is  doubtful,  it  is  better  to  first  insert  an  aspirator-needle  into 
the  breast,  rather  than  to  subject  the  woman  to  a  painful  operation, 
which,  if  misdirected,  may  require  to  be  repeated. 

In  Billroth's  clinic  *  the  following  plan  is  adopted  in  opening  ab- 
scesses of  the  breast :  The  surface  should  first  be  cleansed  with  soap 
and  drenched  with  a  solution  of  carbolic  acid  or  of  thymol.  The 
incision  should  be  a  half-inch  in  length,  and  should  radiate  from  the 
nipple.  A  drainage-tube  should  be  instantly  introduced,  and  the  pus 
should  be  gently  expressed,  after  which  the  breast  should  once  more  be 
bathed  with  a  disinfectant  fluid.  The  entire  breast  should  then  be 
enveloped  in  antiseptic  gauze  covered  with  water-proof  material. 
Finally,  after  packing  the  periphery  with  oakum,  especially  beneath 
the  breast  and  in  the  axilla,  the  dressing  should  be  fastened  with  a 
bandage  extending  over  the  thorax  from  the  neck  to  the  umbilicus. 
In  doing  this,  care  should  be  taken  to  pack  sufficient  cotton  beneath 
and  around  the  sound  breast  to  prevent  its  surface  being  pressed  into 
contact  with  that  of  the  thorax.  If  the  abscess  is  large  and  sinuous, 
the  dressing  should  be  changed  in  twenty-four  hours,  and  then  should 
be  left  in  place  for  from  three  to  five  days.  By  these  means  the  organ  is 
equably  compressed,  the  pus  is  prevented  from  decomposing,  and  the 
discharge  is  promoted,  all  conditions  which  tend  to  produce  a  painless 
course  and  a  rapid  recovery.  If,  while  the  bandage  is  applied,  the 
patient  once  more  suffers  from  pain  and  fever,  it  should  be  removed, 
and  any  new  abscess  in  the  process  of  formation  should  be  opened  and 
treated  in  the  same  manner. 

*  Billroth,  "Ilandbuch  dcr  Fraueukranklicitcn,"  zehiiter  Absclmitt,  p.  23. 


DISEASES  OF  THE  BREAST. 


663 


Bj  the  practice  recommended,  even  in  bad  cases,  the  ugly  scars 
and  deformities  of  the  breast,  which  sometimes  follow  the  older  poul- 
tice treatment,  are  avoided. 

In  fresh  cases  the  pus  is  never  decomposed,  and  irrigation  of  the 
wound  is  unnecessary.  In  old  cases,  on  the  contrary,  which  have 
been  treated  by  small  incisions  and  without  antiseptic  precautions, 
the  pus  is  often  acid  and  possessed  of  irritating  properties.  For 
these  neglected  abscesses,  Billroth  recommends  placing  the  patient 
under  an  anaesthetic,  dilating  the  openings  so  as  to  permit  the  passage 
of  the  finger,  and  breaking  down  the  thin  partitions  between  the 
abscesses  so  as  to  convert  them  as  far  as  possible  into  large  com- 
municating cavities  ;  while  this  process  is  going  on,  the  tube  of  an 
irrigator  should  be  passed  by  the  side  of  the  finger,  and  the  cavity 
should  be  washed  with  a  three-per-cent.  solution  of  carbolic  acid  until 
at  last  the  fluid  comes  away  clear  and  unstained.  A  drainage-tube 
should  then  be  introduced,  and  the  breast  treated  in  the  antiseptic 
manner  already  described. 

It  is  hardly  necessary  to  add  that  the  recovery  of  the  patient  is 
always  aided  by  good  food  and  an  abundance  of  fresh,  pure  air. 

Galactocele. — In  very  rare  cases,  owing  to  the  obliteration  or  stop- 
page of  one  of  the  milk-ducts,  the  sinus  may  become  distended  with 
milk  and  form  a  cyst  termed  a  galactocele.  Usually  it  is  of  small 
size,  but  in  the  often-quoted  case  of  Scarpa  the  breast  attained  such 
dimensions  as  to  reach  to  the  thigh.  Upon  puncturing  the  tumor 
with  a  trocar,  ten  pounds  of  milk  were  removed,  which  in  all  respects 
resembled  human  milk  of  normal  quality. 


IN  D 


EX. 


Abdomeit  : 

appearance  of,  in  pregnancy,  91,  98. 

pain  in,  during  pregnancy,  91. 

size  of,  in  pregnancy,  98. 

Striae  upon,  in  pregnancy,  91. 
Abdominal  muscles,  action  of,  in  labor,  128. 
Abdominal  pregnancy,  310,  315. 
Abdominal  tumors : 

diagnosis  of,  from  pregnancy,  512. 
Abortion  (vide  labor,  premature) : 

anassthesia  in,  304. 

artificial,  333. 
indications  for,  333. 

care  of  child,  after,  333. 

causes,  predisposing,  of,  291. 
atrophy  of  uterine  mucous  membrane, 
292. 

hypertrophy  of  uterine  mucous  mem- 
brane, 293. 
causes,  immediate,  of,  294. 
hypersemia  of  gravid  uterus,  294. 
uterine  contractions,  from  nervous  influ- 
ences, 294. 
definition  of,  291. 
diagnosis  of,  298. 

expulsion  of  placenta,  in,  295,  296. 
incomplete,  results  of,  296. 
indications  for,  326. 

diseases  which  imperil  life  of  mother, 
328. 

habitual  death  of  foetus,  328. 

moderate  pelvic  contraction,  826. 
induction  of,  326. 
membranes,  retention  of,  in,  296. 
methods  for  producing,  332. 
mole,  due  to,  295. 
operations  for  mduction  of,  328. 

catheterization  of  uterus,  329. 

douche,  vaginal,  331. 

injections  between  uterus  and  ovum,  329. 

mechanical  dilatation  of  cervix,  330. 

rupture  of  membranes,  330. 

tampon,  vaginal,  332. 


Abortion : 

ovum-forceps,  use  of,  in,  307. 

polypi,  fibrous,  removal  of,  after,  308. 

prognosis  in,  299. 

prophylaxis  of,  300. 

retention  of  membranes  in,  296. 

symptoms  of,  294. 

tampon,  vaginal,  use  of,  in,  305. 

time  for,  327. 

treatment  of,  300. 
when  inevitable,  302. 
when  neglected,  307. 

treatment,  prophylactic,  300. 

treatment  of  threatened,  301. 
Abscesses,  in  mastitis,  661. 

in  phlegmasia  alba  dolens,  656. 

in  puerperal  fever,  625,  651. 
Acardia,  in  multiple  pregnancy,  223,  519. 
Accidental  htemorrhage,  554,  561. 

treatment  of,  562. 
Accoucheur^  armamentarium  of,  203. 
yEquahiliter  justo-minor  pelvis,  432,  439. 
After-pains,  236. 

Air,  collapse  and  death  from  entry  of,  into 

uterine  vessels,  598. 
Air-passages,  catheterization  of,  in  asplvjxia 

neonatorum^  594. 
Albuminuria,  531. 

in  pregnancy,  95. 

in  eclampsia,  528,  529,  531. 

treatment  of,  535  et  seq. 
Alcohol,  use  of,  in  puerperal  fever,  648. 
Allantois,  49,  50. 
Amaurosis,  in  pregnancy,  95. 
Amblyopia,  in  pregnancy,  95. 
Amenorrhoea,  97. 

Ammonia,  intravenous  injection  of,  in  cere- 
bral aniemia,  547. 
Amnion,  48. 
anomalies  of,  277. 

causing  inertia  uteri ^  422. 
dropsy  of,  277. 
fluid  of,  58. 


666 


INDEX. 


Amniotic  fluid,  anomalies  of,  277. 

deficiency  of,  278. 
Anaemia,  116. 

cerebral,  causing  eclampsia,  534. 
treatment  of,  547. 

in  labor  and  childbed,  597. 

pernicious,  in  pregnancy,  117. 

treatment  of,  117. 
Anaesthetics : 

in  abortion,  304. 

in  eclampsia,  537. 

in  irregular  pains  of  first  stage  of  labor,  424. 

in  midwifer}'^,  219. 
Anaesthesia,  in  pregnancy,  95. 
Anasarca,  fetal,  causing  dystocia,  517. 
Anchylosis  of  fetal  joints,  causing  d}  stocia, 
518. 

Anodynes,  in  protracted  first  stage  of  labor, 
424. 

Anorexia,  in  pregnancy,  117. 
Anteflexion,  in  pregnancy,  2G4. 
Anteversion,  in  pregnancy,  264. 
Antipyretic  treatment  of  puerperal  fever,  6-16. 

by  quinia,  646. 

by  salicylate  of  soda,  647. 
Antiseptic  treatment  of  puerperal  patients, 
641. 

Anus : 

development  of,  62. 

imperforate,  62. 
Aorta,  compression  of,  \n  post-prn'tum  liEcm- 

orrhage,  546. 
Apron,  Hottentot,  4. 

Arbor  vitoe,  uterina^  13. 
Arch,  palatine,  63. 
Arches,  visceral,  62. 

aortic,  67. 
Area^  germinativa^  44,  59,  67. 

opaca^  45,  59. 

pelkicida^  45,  59. 

vasculosa^  45,  67. 
Areola,  mammce,  237. 

of  pregnancy,  92,  94,  98. 

secondary,  of  Montgomery,  92. 
Armamentarium  of  accoucheur,  203. 

for  breech  presentations,  355. 
Arms : 

liberation  of,  in  breech  presentations,  360. 

liberation  of,  when  extended,  360. 

liberation  of,  when  flexed,  360. 

release  of  anterior,  360. 

release  of  posterior,  360. 
Arteria,  uterina  hypogastrica,  22. 

aortica,  23. 
Arteries : 

inferior  vertebral,  67. 

omphalo-mesenteric,  67. 

superior  vertebral,  67. 

vitelline,  67. 


Articulations : 
anchylosis  of  fetal,  obstructing  labor,  518. 
of  fetal  head  with  spinal  column,  166. 
pelvic,  143. 

pelvic,  mobility  of,  in  labor,  273. 

sacro-iliac,  143. 
Artificial  feeding  of  infants,  247. 
Artificial  respiration,  in  asp7ii/xia  neonato- 
rum, 595. 

Schultze's  method  of,  595. 

Marshall  Hall's  method  of,  596. 
Ascites,  fetal,  obstructing  labor,  516. 
Asphyxia  neonatorum,  588. 

definition  of,  588. 

diagnosis  of,  592. 

etiology  of,  588. 

morbid  anatomy  of,  591. 

prognosis  of,  593. 

treatment  of,  596. 
Asphyxia  livida,  591. 

pallida,  591. 
Astringents,  use  of,  in  post-partum  hsemor- 
.    rhage,  543. 

Atony,  uterine,  in  third  stage  of  labor,  429. 
Atresia  of  genital  canal,  500. 

symptoms  of,  506. 

treatment  of,  506. 
Atresia,  uterine,  504. 

from  cervical  thrombus,  505. 

from  cicatrices,  505. 

from  conglutinatio  orificii  externi,  504. 

from  elongation  of  anterior  lip,  505. 

from  ovarian  tumors,  511. 

from  rigidirty  of  os,  505. 

from  tumors,  505. 
Atresia,  vaginal,  501. 

accidental,  501. 

congenital,  501. 

from  cystic  degeneration  of  vaginal  walls, 
503. 

from  cystocele,  502. 
from  ecchinococei,  503. 
from  neoplasmata,  503. 
from  rectocele,  502. 
from  retention  of  urine,  502. 
from  vaginal  hernia,  503. 
from  vaginismus,  603. 
from  vesical  calculi,  502. 
Atresia,  vulvar,  500. 

Atropia,  use  of,  in  protracted  first  stago  of 
labor,  424. 

Atrophy,  of  uterine  mucous  membrane,  caus- 
ing abortion,  292. 
Attitude  of  foetus,  78. 

Auscultation,  as  aid  to  diagnosis  of  pregnan- 
cy, 100. 

Axis: 

of  superior  pelvic  strait,  150. 
of  inferior  pelvic  strait,  151. 


INDEX. 


667 


Bacteria : 

DavaiDe's  experiments  with,  614. 

in  puerperal  fever,  612,  614,  631. 
Ballottement,  100. 

Bandage,  application  of  abdominal,  218. 
Barnes's  dilator : 

use  of,  in  accidental  hsemorrliage,  562. 

use  of,  in  breech  presentations,  201. 

use  of,  in  eclampsia,  538. 

use  of,  in  placenta  prsevia,  559. 

use  of,  in  prolapsed  funis,  584. 

use  of,  in  protracted  first  stage  of  labor,  425. 

use  of,  in  vaginal  thrombus,  580. 

use  of,  to  induce  premature  delivery,  331. 
Bath : 

cold,  in  puei-peral  fever,  648. 

of  new-born  infant,  246. 
Binder,  application  of  abdominal,  218. 
Bladder : 

calculus  in,  obstructing  labor,  502. 

development  of  fetal,  66. 

dilatation  of  fetal,  510. 

distention  of,  obstructing  labor,  502. 
Blastodermic  vesicle,  44. 

membrane,  44. 
Blood,  changes  of,  in  pregnancy,  116. 
Biunt  hook  : 

use  of,  in  craniotomy,  393. 
Bodies,  Wolffian,  28.  ' 
Bottle  for  artificial  feeding  of  infants,  249. 

care  of,  249. 
Bougies,  use  of,  in  protracted  first  stage  of 
labor,  425. 

Bowel,  paralysis  of,  in  puerperal  fever,  626. 
Breech  presentations,  196. 
causes  of,  196. 

configuration  of  foetus  in,  200. 
diagnosis  of,  196. 

irregularities  in  mechanism  of,  199. 
mechanism  of,  197. 
prognosis  in,  200. 
rotation  in,  198. 
treatment  of,  201. 
Breasts  : 

anatomy  of,  237. 

changes  in,  during  pregnancy,  91. 
diseases  of,  657. 
abscesses  of,  661. 
causes  of  mastitis,  601. 
galactocele,  663. 
galactorrhoea,  657. 
^      inflammation  of,  660. 
;      mastitis,  parenchymatous,  660. 
nipples,  sore,  658. 
nii:)ple8,  fissured,  658. 

treatment  of  sore  nipples,  659. 
treatment  of  mastitis,  060. 
in  new-born  cliild,  241, 
symptoms  of,  relating  to  pregnancy,  98. 


Bregma,  164. 

Brim,  of  pelvis,  149  {vide  strait,  superior). 

application  of  forceps  at,  348,  349. 

extraction  with  head  at,  363. 

Tarnier's  forceps  at,  351. 

Taylor's  forceps  at,  350. 
Bromides  : 

use  of,  in  eclanapsia,  538. 

use  of,  in  emesis  of  pregnancy,  119. 

use  of,  in  insomnia,  122. 

use  of,  in  puerperal  insanity,  654. 
Brow  presentations,  192. 

diagnosis  of,  192. 

mechanism  of,  192. 

prognosis  in,  193. 

treatment  of,  194. 
Bruit^  uterine,  in  pregnancy,  101. 
Bulbus  arteriosus^  66. 
Bulhi  vestibuli  vagince^  4. 

pars  intermedia  of,  4. 

CiBsarean  section,  399. 
after-treatment  of,  400. 
assistant's  duties  in,  401. 
checking  hemorrhage  in,  404. 
cleansing  peritonaeum  after,  405. 
closure  of  wound  after,  405. 
dressing  of  wound  after,  405. 
extraction  of  foetus  after,  403. 
liistory  of,  399. 

incision  in  the  abdominal   wall  during, 
401. 

incision  into  uterus  during,  402. 

indications  for,  400. 

instruments  necessary  for,  401. 

operation  of,  400. 

preparations  for,  400. 

prognosis  of,  406. 
causes  forbad,  409. 
in  lying-in  hospitals,  407,  409. 
in  rural  localities,  408. 

removal  of  placenta,  in,  404. 
Calcareous  degeneration : 

of  foetus,  290. 

of  cord,  281. 
Calculi : 

vesical,  obstructing  labor,  502. 

impacted,  mistaken  for  exostoses,  502. 
Canal,  genital, 

atresia  of,  500. 

ruptures  of,  564. 
Cancer,  uterine,  509. 
Caput  succedaneum  : 

in  face  presentations,  188. 

in  vertex  presentations,  179. 
Cardiac  diseases,  complicating  pregnancy, 
256. 

Carunctdoe  myrtiformes  : 
formation  of,  7. 


668 


INDEX. 


Catheterization : 
uterine,  to  produce  premature  delivery, 
329. 

of  air-'psLSSSiges^inasphT/xia  neonatorum^  594. 
Cephalic  version,  366. 
Cephalotomy,  394. 
Cephalotribe,  383. 

action  of,  386. 

application  of,  388. 

Blot's,  384. 

objections  to,  386. 

Lusk's,  385. 

Scanzoni's,  385. 
Cephalotripsy,  386,  388. 
Cervix  uteri,  12,  25. 

apparent  shortening  of,  in  pregnancy,  86. 
explanation  of,  88. 

atresia  of,  505. 

canal  of,  13. 

cancer  of,  509. 

erectility  of,  25. 

in  puerperal  state,  234. 

mechanical  dilatation  of,  to  produce  abor- 
tion, 330. 

mucous  membrane  of,  17. 

portio  vaginalis  of,  12. 
lacerations  of,  573. 

stricture  of,  505. 
Child  {vide  foetus) : 

asphyxia  of,  588. 

-bed,  insanity  of,  652. 

breasts  of  new-born,  241. 

conditions  influencing  size  of,  76, 

icterus  of  new-born,  241. 

milk  prepared  for,  248. 

weight  of  new-born,  76. 
Chill,  post-partum^  230. 

in  puerperal  fever,  622. 
Chloral : 

in  eclampsia,  536,  538,  539. 

in  emesis  of  pregnancy,  120. 

in  insomnia  of  pregnancy,  122. 

in  puerperal  insanity,  654. 
Chloroform : 

effect  of,  on  pains,  220. 

use  of,  in  eclampsia,  537,  539. 

use  of,  in  labor,  220. 
Cholera,  complicating  pregnancy,  252. 
Chorda  dorsalis^  46,  61. 
Chorea,  complicating  pregnancy,  117,  261. 

treatment  of,  262. 
Chorion : 

formation  of,  44,  49. 

permanent,  51. 

villi  of,  50,  52. 
Cicatrices : 

atresia,  uterine,  from,  505. 

of  OS,  obstructing  labor,  505. 

of  vagina,  obstructing  labor,  501. 


Circle  of  Baudelocque,  435. 
Circulation : 

disorders  of,  in  pregnancy,  117, 118. 

fetal,  71. 

varicose  veins  due  to  disorders  of,  in  preg- 
nancy, 118. 
Clefts,  visceral,  62. 
Clitoris : 

anatomy  of,  3. 

corpus  of,  3. 

frenulum  of,  4. 

glans  of,  3. 

prseputium  of,  4. 
Coccyx,  anatomy  of,  141. 
Coelum,  48. 
Coiling  of  cord,  281. 
Cold,  use  of,  in  puerperal  fever,  648. 
Collapse,  in  labor  and  childbed,  597. 

etiology  of,  597. 
Colpohyperplasia  cystica  : 

vaginal  atresia  from,  503. 
Columns,  vaginal,  9. 
Conception,  40. 

Confinement,  prediction  of  day  of,  111. 
Congenital  encephalocele,  515. 
Conglutinatio  orificii  externi : 

atresia  from,  504. 
Conjugate  diameter  of  pelvis  : 

measurement  of  diagonal,  437. 

measurement  of  external,  436. 

measurement  of  vera,  438. 
Constipation : 

in  pregnancy,  92. 

in  retroflexion,  with  incarceration,  266. 
Contracted  pelvis,  432  {vide  pelvis,  con- 
tracted). 

diagnosis  of,  433. 

frequency  of,  432. 

varieties  of,  432, 
•Contraction : 

hour-glass,  of  uterus,  429. 

pelvic,  resources  of  treatment  in,  466. 
Convulsions,  puerperal,  626  {vide  eclamp- 
sia). 

Cord,  umbilical  {^vide  funis) : 
calcareous  degeneration  of,  281. 
care  of,  in  infants,  246. 
coiling  of,  281. 
cysts  of,  281. 
formation  of,  57. 
hernias  of,  280. 
knots  in,  280, 

management  of,  in  breech  presentations, 
359, 

marginal  insertion  of,  282. 
prolapse  of,  582. 
reposition  of,  587. 
souffle  in,  102. 
stenosis  of  vessels  of,  281. 


INDEX. 


669 


Cord,  umbilical : 

torsion  of,  279. 

tying  of,  in  labor,  211. 
Cordiform  uterus,  32. 
Corpus  luteum : 

anatomy  of,  37. 

false,  38. 

formation  of,  37. 

true,  38. 
Cramps  in  pregnancy,  92. 
Cranial  presentations,  168  (vide  presenta- 
tions, vertex). 
Cranioclast,  389. 

action  of,  391. 

application  of,  391. 

Braun's,  390. 

Simpson's,  389. 
Craniotomy  : 

before  version,  394. 

Blot's  cephalotribe  in,  384. 

Blot's  perforator  in,  379. 

Braun's  cranioclast  in,  396. 

contraindications  for,  464. 

contrasted  with  version,  460. 

craniotomy-forceps  of  Meigs  in,  392. 

crotchet  and  blunt  hook  in,  393. 

definition  of,  377. 

extraction  of  child  after,  382. 

Hodge's  craniotomy  scissors  in,  379. 

indications  for  perforation  in,  377. 

instruments  used  in,  378, 383. 

Lusk's  cephalotribe  in,  385. 

operation  of  perforation  in,  377,  381. 

Scanzoni's  cephalotribe  in,  385. 

Simpson's  cranioclast  in,  389. 

Simpson's  perforator  in,  379. 

Smellie's  scissors  in  379. 

Thomas's  perforator  in,  379. 

trephine  perforator  in,  380. 
Cranium,  fetal,  76. 

premature  ossification  of,  513. 
Crotchet,  393. 

delivery  of  trunk  with,  394. 
Cuneus,  2. 

Cyanosis  neonatorum,  72  (vide  aspTiyxia  neo- 
natorum). 
Cystocele : 

atresia,  vaginal,  from,  502. 

obstructing  labor,  502. 
Cysts: 

of  cord,  281. 

of  ovary,  differentiated  from  pregnancy,  104. 
of  vaginal  walls,  503. 

Deafness,  in  pregnancy,  95. 
Death : 

fetal,  diagnosis  of,  109. 

real  or  apparent,  of  mother  in  pregnancy 
or  labor,  599. 


Death : 

delivery  of  child  in,  599. 

sudden,  in  labor  and  childbed,  597. 
Decapitation,  396. 

Braun's  decollator  in,  396. 

in  embryotomy,  395. 

methods  of,  396,  397. 
'     Pajot's  method  of,  397. 
Decidua,  49,  51. 

reflexa,  52. 

separation  of,  233. 

serotina,  52. 

vera,  51. 
Decollator,  Braun's,  396. 

use  of,  in  decapitation,  397. 
Deformities,  pelvic,  432  {vide  pelvis,  con- 
tracted). 

due  to  absence  of  symphysis,  499. 

due  to  exostosis,  498. 

due  to  fractures,  498. 

contracted  pelvis,  432. 

flattened  pelvis,  441. 

funnel-shaped  pelvis,  493. 

generally  contracted  pelvis,  444. 

irregular  forms  of  contracted  pelvis,  445. 

kyphotic  pelvis,  485. 

Naegele  oblique  pelvis,  481. 

osteomalacic  pelvis,  495. 

pseudo-osteomalacic  pelvis,  498. 

Robert's  anchylosed  and  transversely  con- 
tracted pelvis,  489. 

rachitic  pelvis,  442. 

Scholio-rachitic  pelvis,  488. 

Spondolisthetic  pelvis,  491. 
Degeneration : 

calcareous,  of  cord,  281. 

calcareous  of  foetus,  290. 

fatty,  of  fffitus,  289. 

hydatidiform,  of  placenta,  283. 
Delivery : 

care  of  patient  after,  217. 

immature,  definition  of,  291. 
treatment  of,  309. 

premature,  definition  of,  291. 
Development  of  female  organs  of  genera- 
tion, 28. 
Diameters  of  pelvis,  150. 

bis-iliac,  150. 

conjugate,  150,  438. 

diagonal  conjugate,  436. 

oblique,  150. 

transverse,  150. 
Diameters  of  fetal  head,  164. 
Diet,  in  ptierperal  state,  244. 
Digestion : 

disorders  of,  in  pregnancy,  94,  119,  121. 

of  new-born  infant,  241. 
Digital  examination  in  labor,  203. 
Digitalis,  use  of,  in  puerperal  fever,  647. 


'670 


INDEX. 


Dilator,  Barnes's : 
use  of,  in  accidental  hsemorrhage,  562. 
use  of,  in  breech  presentations,  '201. 
use  of,  in  eclampsia,  538. 
use  of,  in  placenta  prasvia,  559. 
use  of,  in  prolapsed  funis,  584. 
use  of,  in  protracted  first  stage  of  labor, 
425. 

use  of,  in  vaginal  thrombus,  580. 

use  of,  to  induce  premature  delivery,  331. 
Diphtheritic  patches : 

in  puerperal  fever,  617,  163. 
Discus  proligerus^  35. 

Diseases,  complicating  pregnancy,  250  (vide 
pregnancy,  diseases  complicating), 
anomalies  of  cord,  279  et  seq. 
cardiac  diseases,  256. 
cholera,  252. 
chorea,  261. 
coiling  of  cord,  281. 
cysts  of  cord,  282. 
degenerations  of  cord,  281. 
emphysema,  258. 
empyema,  258. 
endometritis  decidua,  270. 
hernias  of  cord,  280. 
hydatidiform  mole,  283, 
icterus,  255. 

maceration  of  foetus,  288. 
malarial  fever,  254. 
mummification  of  foetus,  288. 
phthisis  pulnionalis,  259. 
pleurisy,  258. 

pneumonia,  acute  lobar,  257. 

relapsing  fever,  253. 

rubeola,  251. 

scarlatina,  251. 

small-pox,  251. 

syphilis,  259. 

typhoid  fever,  253. 

typhus  fever,  253. 

variola,  251. 
Displacements,  of  uterus,  264,  265  {vide  ute- 
rus, displacements  of). 
Dolores  presarjientes^  130. 
Dorsal  plates,  40,  59. 
Double  uterus,  263. 
Douglas,  cul-de-sac  of,  7,  14. 
Douche,  vaginal : 

in  protracted  first  stage  of  labor,  425. 

to  produce  premature  delivery,  331. 

to  prevent  puerperal  lever,  642. 
Dropsy : 

complicating  pregnancy,  117.  * 

of  amnion,  277. 
Ducts : 

of  Mull er,  28. 

Wolffian,  28. 
Ductus^  arteriosus^  69. 


Ductus^  venosHs,  71. 
Dystocia,  from  fetal  emphysema,  517. 
Dysuria,  from  retroflexion  of  gravid  uterus 
with  incarceration,  266. 

Echinococci,  vaginal  atresia  from,  503. 
Eclampsia,  526. 

clinical  history  of,  526. 

definition  of,  520. 

etiology  of,  529. 

pathology  of,  529. 

prognosis  in,  528. 

terminations  of,  528. 

treatment  of.  635. 

use  of  bromides  in,  538. 

use  of  chloral  in,  536,  538,  539. 

use  of  chloroform  in,  537,  539. 
J^craseur,  Hicks's  wire,  in  cephalotomy,  394. 
Ectoderm,  44. 

Ectopia  of  abdominal  organs  obstructing  la 

bor,  517. 
Electricity : 

in  emesis  of  pregnancy,  119. 

in  extra-uterine  pregnancy,  320. 

in  post-partum  haemorrhage,  546. 
Elytrotomy  in  extra-uterine  pregnancy,  320. 
Embolus : 

collapse  and  death  from  pulmonary,  in  la- 
bor and  childbed,  598. 

symptoms,  598. 

treatment,  599. 
Embryo : 

anatomy  of,  46. 

nourishment  of,  48. 
Embryotome : 
!     of  P.  Thomas,  398. 
Embryotomy,  377,  395. 

decapitation  in,  396. 

exenteration  in,  395, 

indications  for,  395, 
Emesis : 

in  incarceration  of  retroflexed  uterus,  266. 

in  pregnancy,  119. 

in  puei-peral  fever,  623,  627. 
Emphysema : 

complicating  pregnancy,  258. 

fetal,  causing  dystocia,  517. 
Empyema : 

complicating  pregnancy,  258. 
Encephalocele,  congenital,  515. 
Endocarditis  tdcerosa  puerperalis^  618. 
Endochorion,  51. 

Endometritis   decidua^   complicating  preg 

nancy,  270. 
Endometritis  decidua  catarrJialis^  or  Tiydror 

rlma  gravidarum^  272. 
Endometritis  decidua  chronica  diffusa^  270. 
Endometritis  decidua  pohjposa^  270. 
Endometritis  decidua  tuberosa,  270. 


INDEX. 


671 


Enema,  in  labor,  205. 
Entoderm,  44. 
Erectility : 
cervical,  25. 

ovarian  (theoretical),  23. 
vaginal,  8. 
Ergot : 

contraindications  for,  in  parturition,  428. 
indications  for,  in  parturition,  429. 
physiological  action  of,  429. 
use  of,  after  normal  labor,  217. 
use  of,  in  accidental  hasmon-hage,  562. 
iise  of,  in  parturition,  428. 
use  of,  in  placenta  prasvia,  560,  501. 
use  of,  in  post-part  urn  haemorrhage,  543. 
use  of,  in  protracted  first  stage  of  labor, 
426. 

Erysipelas,  how  related  to  puei-peral  fever, 
618. 

Eustachian  valve,  68. 

Evolutio  conduplicato  corpore^  525. 

prognosis,  525. 
Evolution,  spontaneous,  523. 

etiology  of,  524. 

mechanism  of,  524. 
Examination  of  patient  in  labor  : 

method  of  conducting,  106,  107,  203. 
Exanthemata  in  pregnancy,  251. 
Excavatio  : 

recto-uterina^  14. 

-vesico-vterina^  14. 
Exochorion,  51. 

Exostosis,  pelvic  deformity  from,  498. 
Expression  of  placenta : 
by  Crede's  method,  215. 
in  irregular  pains  of  third  stage  of  labor, 
429. 

Extraction  of  foetus : 

by  breech,  in  breech  presentations,  357. 

by  feet,  in  breech  presentations,  356. 

in  Csesarean  section,  403. 

in  foot  and  breech  presentations,  354. 

in  pelvic  presentations,  354. 

in  real  or  apparent  death  of  mother  in  preg- 
nancy or  labor,  599. 

relief  of  arms  in,  360. 
Extraction  of  head,  362. 
Extraction  of  trunk  to  shoulders,  356. 
E.xtra-uterine   pregnancy,  309  {tide  preg- 
nancy, extra-uterine). 

abdominal,  310,  315. 

definition  of,  310. 

diagnosis  of,  318. 

interstitial,  313. 

ovarian,  310,  315. 

symptoms  of,  316. 

terminations  of,  317. 

tubal,  310. 

tubo-abdominal,  314. 


i  Extra-uterine  pregnancy : 
tubo-ovarian,  314. 
treatment  of,  319. 

(a)  in  cases  of  early  gestation,  319. 
{b)  in  cases  of  advanced  gestation,  322. 
{c)  in  cases  of  gestation,  after  death  of 
foetus,  324. 

Face,  development  of,  63. 
Face  presentations,  184  {vide  presentations, 
face). 

abnormal  mechanism  of,  186, 
causes  of,  182. 

configuration  of  head  in,  188. 

diagnosis  of,  189. 

frequency  of,  182. 
i  mechanism  of,  184. 
I  prognosis  in,  189. 
I  treatment  of,  190. 
I  Fallopian  tubes,  18. 
j     ampulla  of,  19. 

anatomy  of,  18. 

isthmus  of,  19. 
j     ostium  abdominale  of,  19. 
Fatty  degeneration  of  foetus,  289. 
Fecundation,  40. 

Feeding,  artificial,  of  infants,  247. 
Fever : 

-cot,  use  of,  in  puerperal  fever,  049. 
malarial,  complicating  pregnancy,  254. 
milk,  238. 

puei-peral,  602  {vide  puerperal  fever). 

relapsing,  253  (in  pregnancy). 

typhoid,  253  (in  pregnancy). 

typhus,  253  (in  pregnancy). 
:  Fibroid  tumors,  diflferential  diagnosis  of,  from 
pregnancy,  104. 
Fillet,  use  of,  in  version,  375. 
Flattened  pelvis,  441. 

non-rachitic,  441. 

rachitic,  442. 
Flatulence  in  pregnancy,  115. 
Floor,  pelvic  or  perineal,  158. 
Fluid,  amniotic,  58. 

anomalies  of,  277. 

deficiency  of,  278. 
Foetus : 

abdominal  enlargement  of,  obstructing  de- 
livery, 516. 

abnormalities  of,  obstructing  labor,  513. 

abnormalities  of,  obstructing  delivery  of 
trunk,  516. 

ascites  of,  obstructing  delivery,  516. 

at  term,  75. 

attitude  of,  78  et  seq. 

causes  of  death  of,  291. 

circulation  of,  71. 

congenital  hydrocephalus  of,  513. 

cranium  of,  76. 


672 


INDEX. 


Foetus : 
degeneration,  fatty,  of,  289. 
degeneration  of  liver  of,  517. 
development  of,  59. 
diagnosis  of  death  of,  109. 
diameters  of  head  of,  164. 
diseases  of,  obstructing  delivery  of  its  head, 
513. 

eneephalocele  of,  obstructing  labor,  515. 
extraction  of: 

by  breech,  357. 

by  feet,  356. 

in  breech  and  foot  presentations,  354. 

in  craniotomy,  382. 

in  pelvic  presentations,  354. 

instruments  for,  383. 

with  head  at  brim,  362. 
fatty  degeneration  of,  289. 
habitual  death  of,  as  cause  for  inducing 

abortion,  328. 
head  of,  at  term,  163. 
heart-sounds  of,  in  pregnancy,  100. 
hydrocephalus  of,  obstructing  labor,  513. 
hydrothorax  of,  obstructing  labor,  516. 
in  first  month,  72. 
in  second  month,  73, 
in  third  month,  73. 
in  fourth  to  eighth  month,  74. 
in  ninth  to  tenth  month,  75. 
length  of,  at  term,  75. 
liver  of,  fatty  degeneration  of,  517. 
maceration  of,  288. 
monstrosities  developed  from,  518. 
movements  of,  in  pregnancy,  99,  113, 

active  and  passive,  99. 
mummification  of,  288. 
papyraceus,  224. 
position  of,  178  et  seq. 
release  of  arms  of,  360, 
retention,  in  xdero^  of  dead,  287. 
tumors  of  trunk  of,  obstructing  labor,  517. 
weight  of,  at  term,  76. 
Follicles,Graafian,  33  {vide  Graafian  follicles), 
Fontanelles,  77,  163, 
large,  77,  164. 
small,  77,  164. 
Foramen  ovale^  68. 

valve  of,  69, 
Forceps,  334, 
action  of,  339, 
application  of,  343. 

to  after-coming  head,  365. 
at  the  pelvic  brim,  348, 
at  the  pelvic  outlet,  341. 
Chamberlen's,  336. 
Chapman's,  336. 

contrasted  with  version  and  craniotomy, 

460  et  seq. 
craniotomy  of  Meigs,  modified,  392. 


Forceps : 

Hodge's,  339. 
history  of,  335. 
indications  for,  340. 

at  pelvic  outlet,  341. 
in  contracted  pelvis,  477. 
in  craniotomy,  383. 
in  face  presentations,  353. 
in  occipito-posterior  positions,  352. 
in  placenta  prsevia,  560. 
in  vaginal  thrombus,  580. 
introduction  of  blades  of,  344. 
Levret's,  337. 
locking  of,  345. 
long,  337. 

Lusk's  modification  of  Tarnier's,  352. 
Naegele's,  338. 

ovum-,  use  of,  in  abortion,  307. 
removal  of,  348. 
short,  336. 
Simpson's,  338. 
Tarnier's,  351. 

Tarnier's,  modified  by  Lusk,  352. 
Taylor's,  at  brim,  350. 
Taylor's  narrow-bladed,  350. 
traction  on,  direction  of,  347. 
Wallace's,  339. 
White's,  339. 
Fornix,  8. 

Fossse,  nasal,  development  of,  62. 
Fourchette,  4. 

Fractures,  causing  pelvic  deformities,  498. 

Frenulum  vuhce^  4, 

Frenulum  clitoridis^  4. 

Fundus  of  uterus,  12. 

Funic  soufile,  102. 

Funis,  57  {vide  cord,  umbilical). 

anomalies  of,  279, 

calcareous  degeneration  of,  281. 

care  of,  in  infants,  246. 

coiling  of,  281. 

cysts  in,  281. 

diseases  of,  281, 

formation  of,  57. 

hernias  of,  280. 

knots  in,  280, 

management  of,  in  breech  presentation,  359. 
marginal  insertion  of,  282. 
prolapse  of,  582. 

diagnosis  of,  583. 

prognosis  of,  583. 

treatment  of,  584. 
reposition  of,  587. 

by  postural  treatment,  585. 
souffle  in,  102. 
stenosis  of  vessels  of,  281. 
torsion  of,  279, 
tying,  in  labor,  211. 
Funnel-shaped  pelvis,  493. 


INDEX. 


673 


Galactocele,  663. 

Galactorrhoea,  657. 

Ganglion,  cervical,  2T. 

Gastrotomy  {vide  Csesarean  section). 

in  uterine  rupture,  572. 
Gelatine,  of  Wharton,  57. 
Generation : 

anatomy  of  female  organs  of,  1. 

development  of  female  organs  of,  28. 
Genital  canal : 

ruptures  of,  564. 

uterine  atresia  of,  504. 

vaginal  atresia  of,  501. 
Germinative  spot,  37. 
Germinative  vesicle,  37. 
Germs,  in  puerperal  fever,  616. 

bacteria,  612,  614,  631. 

micrococci,  612,  631. 
Glandulce.  xestibulares : 

majores^  6. 

minores^  5. 
Glands : 

mammary,  anatomy  and  changes  of,  in 
pregnancy,  91,  237. 

sebaceous,  of  nymphse,  5. 

uterine,  16. 
Glans  clUoridis,  3. 
Graafian  follicles,  33,  36. 

macula  of,  37. 

number  of,  37. 

stigma  of,  37. 

theca  folliculi  of,  35. 

tunica  jibi'osa  of,  35. 

tunic%  propria  of,  35. 
Gravid  uterus : 

anteflexion  of,  264. 

anteversiou  of,  264. 

hernia  of,  269. 

prolapse  of,  268. 

retroflexion  of,  265. 
with  incarceration,  266. 
treatment  of,  267. 

retroversion  of,  265. 

Hare-lip : 

complicated,  63. 

double,  63. 

single,  63. 
Head,  fetal : 

after-coming,  forceps  applied  to,  365. 

at  term,  163. 

configuration  of,  in  vertex  presentations,  178. 
descent  and  extension  of,  in  face  presenta- 
tions, 184. 
descent  and  flexion  of,  in  labor,  169. 
diseases  which  obstruct  delivery  of,  513. 
entrance  of,  into  pelvis,  168. 
extension  of,  in  labor,  175. 
external  rotation  of,  in  labor,  176. 


Head,  fetal: 
external  rotation  of,  in  face  presentations, 
186. 

flexion  of,  in  face  presentations,  186. 

molding  of,  in  vertex  presentations,  178. 

rotation  of,  in  labor,  172. 

rotation  of,  in  face  presentations,  185. 

scalp-tumor  on,  179. 
Headache  in  pregnancy,  122. 
Heart : 

development  of,  66. 

diseases  of,  complicating  pregnancy,  256. 

-sounds,  fetal,  in  pregnancy,  100. 
Heart-burn,  in  pregnancy,  115,  121. 
Hemicephalus,  521. 
Haemorrhage : 

accidental,  554,  561. 

concealed,  562. 

external,  562. 

from  cervical  laceration,  574. 
from  normally  implanted  placenta,  561. 
in  Csesarean  section,  control  of,  404. 
in  placenta  prsevia,  554. 
internal,  562.  ^ 
fost-partum^  539. 
causes  of,  541,  542. 

disturbances  of  contractility  as  cause  of, 
541. 

disturbances  of  retractility  as  cause  of, 
541. 

disturbances  of  thrombus-formation  caus- 
ing, 542. 

electricity,  use  of,  in,  546. 

intra- uterine  injections  in,  544. 

methods  of  producing  uterine  retractions 
in,  546. 

methods  of  producing  uterine  contractions 
in,  542. 

normal  agencies  for  checking,  539. 
outlying  causes  of,  542. 
transfusion  of  blood  in,  548. 
transfusion  of  milk  in,  548. 
treatment  of,  542. 

treatment  of  cerebral  antemia  in,  547 

puerperal,  549. 

unavoidable,  554. 
Hernia : 

of  cord,  280. 

of  gravid  uterus,  269. 

of  vagina,  atresia  from,  503. 
Hiatus  sacralis^  140. 
Hook: 

blunt,  393. 

Braun's  decapitating,  396. 

Eambotham's  decapitating,  397. 
Hour-glass  contraction  of  uterus,  429. 
Hydatidiform  mole : 

anatomy,  morbid,  of,  283. 

diagnosis  of,  286. 


43 


674 


INDEX. 


Hydatidiform  mole : 

etiology  of,  284. 

prognosis  of,  286. 

symptoms  of,  285. 

treatment  of,  280. 
Hydramnion,  277. 

as  cause  of  tardy  labor,  422. 

diagnosis  of,  278. 

etiology  of,  277. 

prognosis  of,  278. 

symptoms  and  signs  of,  277. 

treatment  of,  278. 
Hydrocephalus,  613. 

diagnosis  of,  514. 

etiology  of,  514. 

mechanism  of  labor  in,  514. 

morbid  anatomy  of,  514. 

prognosis  in,  515. 
Hijdrorrlios,a  gravidaricm^  272. 
Hydrothorax : 

fetal,  obstructing  labor,  516. 
Hygiene  of  pregnancy,  115. 
Hymen : 

anatomy  of,  6. 

annularis,  6. 

cribriformis,  6. 

fimbriatus,  6. 

imperforatus,  6. 
Hypertrophy  : 

of  uterine  mucous  membrane,  causing  abor- 
tion, 293. 
Hysteria : 

in  pregnancy,  117. 
Hysterotomy,  399  {vide  Csesarean  section). 

Icterus : 

neonatorum^  241. 

in  pregnancy,  255. 
Heus : 

due  to  retroflexcd  gravid  uterus,  266. 
Ilia,  anatomy  of,  141. 
Impregnation,  40  {vide  fecundation). 
Incarceration  of  retroflexcd  gravid  uterus, 
266. 

treatment  of,  267. 
Inertia  titeri^  422,  429. 

causes  of,  422. 

treatment  of,  423. 
Infant,  new-born,  241. 

artificial  feeding  of,  247. 

bath  of,  246. 

care  of,  246. 

care  of  cord  of,  246. 

changes  in  circulation  of,  241. 

digestion  of,  241. 

icterus  of,  241. 

loss  of  weight  of,  242. 

navel  of,  241. 

selecting  wet-nurse  for,  246. 


Infant,  new-bom: 
skin  of,  241. 

tumor  on  presenting  part  of,  241. 
umbilicus  of,  241. 
Infectious  diseases : 

complicating  pregnancy,  251. 
Injections : 
between  uterus  and  ovum,  to  produce 

abortion,  329. 
intra-uterine,  in  jjost-partum  hasmon-hage, 
544.  ^ 

intra-uterine,  in  puerperal  fever,  643. 
vaginal, 

in  protracted  first  stage  of  labor,  425. 
to  produce  abortion,  331. 
to  prevent  puerperal  fever,  642. 
Insanity : 

in  pregnancy,'  117,  652. 

of  lactation,  655. 

puerperal,  652. 
Insertion : 

marginal,  of  cord,  282. 
Insomnia,  in  pregnancy,  122. 
Insufflation : 

in  asphyxia  neonatorum^  595. 
Intestine : 

development  of,  62,  65,  66. 
Inversio  ^iteri^  563. 
Involution,  uterme,  232. 
Iron : 

injection  of,  vapost-partiim  htemorrhagc,  544. 
use  of,  in  vaginal  thrombus,  580. 
Iscliia,  anatomy  of,  143. 

Jaundice : 

in  new-born  child,  241. 

in  pregnancy,  255. 
Jaw,  development  of,  63. 
Joints : 

anchylosis  of,  fetal,  obstructing  labor,  518. 
mobility  of  pelvic,  in  labor,  273. 
pelvic,  143. 
sacro-iliac,  143. 

Kibble's  cot : 

use  of,  in  puerperal  fever,  649. 
Kidneys : 

cystic  degeneration  of  fetal,  516. 

pathological  changes  of,  in  eclampsia,  531 
et  seg. 

Knots  in  umbilical  cord,  280. 
Kyphotic  pelvis,  446,  485. 

Labia  majora,  2, 
commissures,  anterior  and  posterior  of,  3. 
oedema  of,  in  pregnancy  and  parturition, 

118,  130,  535. 
thrombosis  of,  4. 
minora,  4. 

sebaceous  glands  of,  5. 


INDEX. 


675 


Labor : 

action  of  abdominal  muscles  in,  12S. 

action  of  expellent  forces  in,  13-4. 

action  of  pains  on  uterine  walls  in,  127. 

action  of  vagina  in,  129. 

anaesthetics  in,  219. 

causes  of,  123. 

chloroform  in,  220. 

clinical  course,  122,  130. 

contraction  of  uterine  ligaments  in,  12S. 

duration  of,  134. 

dry,  423. 

false,  431. 

mechanism  of: 

abnormal,  in  vertex  presentations,  177. 

in  abnormal  face  presentations,  186. 

in  breech  presentations,  196. 

in  brow  presentations,  192. 

in  face  presentations,  184. 

in  irregular  breech  presentations,  199. 

in  normal  presentations,  169. 

in  occipito-posterior  positions,  177. 
missed,  290. 
normal : 

anaesthetics  in,  219. 

care  of  patient  after,  217. 

chloroform  in,  220. 

conduction  of,  202. 

examination  of  patient  in,  203. 

management  of  first  stage  of,  204. 

management  of  second  stage  of,  205. 

management  of  third  stage  of,  215. 

preliminary  preparations  for,  203. 

preservation  of  perinaeum  in,  207. 

treatment  of  lacerations  after,  218. 

tying  cord  in,  211. 
obstructed  {vide  obstructed  labor), 
painful,  430. 

cessation  of,  after  diaphoresis,  431. 

from  hysteria,  430. 

from  inflammation  of  or  around  genital 
organs,  431. 

from  intestinal  irritation,  431. 

from  rheumatism,  431. 
pains  of,  129. 

influence  of,  on  organism,  129. 
pathological,  419. 
precipitate,  420. 

consequences  of,  420. 

treatment  of,  420, 
premature,  291,  467. 

care  of  cliild  after,  333. 

catheterization  of  uterus    to  produce, 
329, 

choice  of  methods  to  produce,  332. 
indications  for,  326,  465. 
induction  of,  326. 

injections  between  uterus  and  ovum  to 
produce,  329. 


Labor : 

mechanical  dilatation  of  cervix  to  pro- 
duce, 330. 
operations  to  produce,  328. 
rupture  of  membranes  to  produce,  330. 
tampon,  vaginal,  to  produce,  332. 
vaginal  douche  to  produce,  331. 
stage  of: 
first,  130. 

second,  or  stage  of  expulsion,  133. 

third,  or  placental  period,  133. 
symptoms,  precursory,  of,  130. 
tardy,  421. 

anodynes  in,  424. 

Barnes's  dilator  in,  425. 

bougies  in,  425. 

douche,  vaginal,  in,  425. 

ergot  in,  426. 

expression  of  placenta  in,  429. 
hour-glass  contractions  of  uterus  in,  429. 
irregular  pains  in  first  stage  of,  421. 
irregular  pains  in  second  stage  of,  426. 
irregular  pains  in  third  stage  of,  429. 
quinia  in,  426. 

treatment  of,  421,  427,  429,  430. 

uterine  ligaments  : 
contraction  of,  in,  128. 

uterine  contractions  in,  127. 
Laceration : 

at  vaginal  orifice,  575. 

of  cervix,  treatment  of,  after  labor,  218, 

of  genital  canal,  564. 

of  pcrinseum,  218,  576. 

of  uterus,  564. 

of  vagina,  575. 

of  vestibulum,  575. 
Lactation,  237. 

fever  of,  238. 

insanity  of,  652. 
Laparotomy  {vide  gastrotomy) : 

in  extra-uterine  pregnancy,  322. 
Laparo-elytrotomy,  415,  461. 

details  of  operation  for,  417. 

history  of,  415. 
Laxatives  in  puerperal  fever,  646. 
Leeches : 

in  puerperal  fever,  64G. 
Ligamenta  lata,  14. 
Ligament,  round,  15. 
Ligaments : 

broad,  14. 

pelvic,  145. 

recto-uterine,  15. 

vesico-uterinc,  14. 
Lig amentum  : 

ovarii,  20, 

teres,  15. 
Liquor  amnii,  58. 
Lithopaedion,  287,  290. 


676 


INDEX. 


Liver : 

development  of,  65, 

degeneration  of  fetal,  517. 
Lochia,  236. 

alba,  237. 

lactea,  237. 

rubra,  236. 

serosa,  236. 
Locking : 

of  children  in  multiple  pregnancies,  227. 

of  forceps,  345. 
Locomotion ; 

impeded  in  labor,  92,  130. 
Lungs,  development  of,  64. 
Lying-in  period : 

duration  of,  246. 
Lymphatics  of  uterus : 

inflammation  of,  in  puerperal  fever,  628. 

Maceration : 

of  foetus,  288. 
Macula  folliculi^  37. 

Malai-ial  fever  complicating  pregnancy,  254. 
Malformations  {vide  monstrosities)  : 

of  child,  518. 
Mamma : 

anatomy  of,  91,  237. 

changes  of,  in  pregnancy,  91. 

diseases  of,  657. 

secretion  of  milk  in,  237. 
Mastitis,  parenchymatous,  660. 
Mania  {vide  insanity ) : 

puerperal,  653. 

treatment  of,  654. 
Marginal  insertion  of  cord,  282. 
Meatus  urethrce^  5. 
Meconium,  75. 
Mechanism : 

abnormal,  in  vertex  presentations,  177. 

of  abnormal  face  presentations,  186. 

of  breech  presentations,  197. 

of  breech  presentations,  irregularities  in, 
199. 

of  brow  presentations,  192. 

of  face  presentations,  184. 

of  labor,  139. 

of  normal  labor,  169. 

of  occipito-posterior  positions,  177. 
Melancholia  {vide  insanity) : 

in  pregnancy,  652. 

treatment  of,  654. 
Memhrana  granulosa^  36. 
Membrane,  blastodermic,  44. 
Membranes : 

artificial  rupture  of,  205. 

rupture  of,  to  produce  abortion,  330. 

spontaneous  rupture  of,  205. 
Menses : 

suppression  of,  in  pregnancy,  96. 


Menstruation,  37  et  seq. 
Mesoderm,  45. 

Metritis,  as  result  of  retroflexion  of  gravid 

uterus,  26G. 
Micrococci : 

Davaine's  experiments  with,  614. 

in  puerperal  fever,  612,  631. 
Micropyle,  of  Keber,  42. 
Microspores,  in  puerperal  fever,  612,  631. 
Microsporum  sepiicum^  615. 
Migration  of  ovum,  39. 
Milk,  237. 

anatomical  considerations  relating  to,  237. 
condensed,  248. 
composition  of,  239. 
fever,  238. 

preparation  of,  for  infants,  248. 

secretion  of,  237. 
defective,  657. 
Milk-leg,  655  {vide  plilegmasia  alba  dolens). 
Miscarriage  {vide  abortion),  291. 

time  of  greatest  liability  to,  116. 

treatment  of,  309. 
Missed  labor,  290. 
Mola : 

carnosa^  296. 

sanguinosa^  295. 
Mole,  hydatidiform,  283. 

anatomy,  morbid,  of,  283. 

diagnosis,  286. 

due  to  abortion,  295. 

etiology,  284. 

prognosis,  286. 

symptoms,  285. 

treatment,  286. 
Mons  Veneris^  2,  15. 
Monstrosities,  518. 

acardiacus,  519. 

anencephalus,  521. 

diagnosis  of,  518. 

hemicephalus,  521. 

mechanism  of  labor  with,  519. 

prognosis  in  cases  of,  619. 
Morbus  coxariiis : 

causing  pelvic  deformities,  483. 
Morning-sickness  of  pregnancy,  119. 
Morsus  diahoU^  19. 
Morula,  4i4,. 
Morphia  {vide  opium) : 

in  eclampsia,  537. 

in  post-partum  haemorrhage,  543. 

in  protracted  first  stage  of  labor,  424. 

in  puerperal  fever,  645. 
Movements,  fetal,  in  pregnancy,  99. 

active,  99. 

passive,  99. 
Mliller's  duets,  28. 
Multiple  pregnancies,  221. 

acardia  in,  223. 


INDEX. 


677 


Multiple  pregnancies : 
conduct  of  labor  in,  229. 
development  of  children  in,  224. 
diagnosis  of,  224. 

entrance,  simultaneous,  of  both  cliildren 

into  pelvis,  in,  226. 
f(v.tus  papyraceus  in,  224. 
frequency  of,  221. 
labor  in,  225. 

locking,  of  children,  in,  227. 

management  of,  221. 

origin  of,  221. 

presentations  in,  225. 

prognosis  in,  228. 

varieties  of,  221. 

weight  of  children  in,  223. 
Mummification : 

of  foetus,  288. 
Myomata,  uterine,  506  {vide  uterus,  myomata 
of). 

Naegele  oblique  pelvis,  481. 
Nasal  fossae : 

development  of,  62. 
Nausea  of  pregnancy,  119. 
Navel : 

changes  of,  in  pregnancy,  90,  103. 

of  new-born  child,  241. 
Neoplasmata : 

placental,  275. 

uterine  atresia  from,  503. 

vaginal  atresia  from,  503. 
Nephelu  vulgaris : 

fecundation  of  ova  of,  42. 
Nerves  of  uterus,  27. 
Nervous  system : 

diseases  of,  in  pregnancy,  117,  121,  122. 
Neuralgia,  in  pregnancy,  92,  95,  121. 
New  formations  in  placenta,  275. 
Newly-born  child : 

asphyxia  of,  588. 

breasts  of,  241. 

icterus  of,  241. 

milk  prepared  for,  248. 

size  of,  76. 

weight  of,  76. 
Nipples : 

changes  in,  during  pregnancy,  91. 

fissured,  658. 

sore,  658. 
treatment  of,  659,  660. 
Nurse : 

wet,  selection  of,  246. 
Nursing : 

in  pregnancy,  245. 
Nijctalopia : 

in  pregnancy,  95. 
Nymphae,  4  {vide  labia  minora). 

sebaceous  glands  of,  5. 


Obstructed  labor,  due  to — 
abnormalities  of  foetus,  513  {vide  foetus), 
anchylosis  of  fetal  joints,  518. 
arm,  extended,  360. 
ascites,  fetal,  516. 
atresia,  uterine,  504  {vide  atresia), 
atresia,  vaginal,  501. 
atresia,  vulvar,  500. 
bladder,  distended,  502. 
coiling  of  cord,  279. 
cystocele,  502. 

displacements,  uterine,  264,  265. 
fatty  growths,  289. 
faces,  impacted,  205. 
fibrous  growths,  503. 
hernias,  vaginal,  503. 
hydrocephalus,  fetal,  513. 
hydrothorax,  fetal,  516. 
hypertrophy  of  cervix,  505. 
hymen,  persistent,  500. 
knots  of  cord,  280. 
locked  twins,  227. 

morbid  growths  of    genital  canal,  603, 
505. 

monstrosities,  518. 
multiple  pregnancy,  225. 
ovarian  tumors,  511. 

ossification  of  fontanelles,  premature,  513. 

perinaeum,  rigid,  501. 

spina  bifida,  517. 

tumors,  intrapelvic,  503,  505. 

Odontalgia,  in  pregnancy,  95. 
(Edema : 

cervical,  in  labor,  505. 

in  eclampsia,  535. 

in  labor,  130. 

in  pregnancy,  92,  118,  535. 
vulvar,  in  labor,  130,  505. 
vulvar,  in  pregnancy,  118,  266. 
Omphalo-mesenteric  artery,  67. 
Operation : 
for  Caesarean  section,  400. 
for  embryotomy,  395,  396. 
for  extrp.ction  of  foetus  in  breech  presen- 
tations, 356. 
for  perforation  in  craniotomy,  377,  381. 
for  producing  abortion,  328. 
Forro's,  411. 

history  of,  412. 

details  of,  413. 
Thomas's,  or  laparo-elytrotomy,  415,  461. 

history  of,  415. 

details  of,  417. 
Opiates : 
in  eclampsia,  537. 
\x\  post-part  am  hemorrhage,  543. 
in  protracted  first  stage  of  labor,  424. 
in  puerperal  fever,  645. 


678 


INDEX. 


Organs  ot  .generation : 

anatomy  of  temale,  1. 

abnormalities  of,  500. 

changes  in,  during  pregnancy,  82  et  ssq. 

development  of,  23. 
Orifice,  oral,  development  of,  62. 
Orificium  vaginx,,  6. 
Os  innominatum,  anatomy  of,  141. 
Osteomalacia : 

pelvic  deformity  from,  495. 

pseudo-,  498. 
6*5,  tincx^  12. 

internmn,  13. 
Os  uteri  : 

changes  of,  in  pregnancy,  80,  98. 

dilatation  of,  in  labor,  131,  13G. 
causes  of,  136,  137. 

elongation  of  anterior  lip  of,  in  labor,  505. 

oedema  of  anterior  lip  of,  in  labor,  505. 

rigidity  of,  atresia  from,  505. 

thrombus  of,  in  labor,  505. 
Ovarian  : 

pregnancy,  310,  315, 

tumors,  diagnosis  of,  512. 

tumors,  obstructing  labor,  511. 
Ovaries : 

anatomy  of,  20. 

arteries  of,  24. 

cortical  substance  of,  22. 

discharge  of  ovum  from,  37. 

erectility,  theoretical,  of,  26. 

ligament  of,  20. 

medullary  substance  of,  21. 

tumors  of,  in  pregnancy  and  the  puorperal 
state,  511,  512. 
diagnosis  of,  512. 

tunica  alhiiginea,  of,  21. 
Ovaxo-hystorectomy^  411. 

history  of,  412. 

details  of,  41 3. 
Ovulation,  37. 
Ovum : 

anatomy  of,  36. 

changes  in,  subsequent  to  fecundation,  42. 

development  of,  33. 

discharge  of,  from  ovary,  37. 

discus  froligerus  of,  35. 

germinativc  spot  of,  37. 

germinativc  vesicle  of,  37. 

memhrana  granulosa  of,  36. 

migration  of,  39. 
■  premature  expulsion  of,  291. 

segmentation  of,  43. 

vitelline  membrano  of,  36, 

vitellus  of,  37. 

yolk  of,  37. 

zona  pellucida  of,  37. 
Ovum-forceps: 

use  of,  in  abortion,  307. 


I  Oxytocics : 

contraindications  for,  428. 

indications  for,  429. 

in  accidental  hemorrhage,  562. 

in  parturition,  428. 

in  placenta  previa,  560,  561. 

\n  post-partum  hsemoiThage,  543. 

in  protracted  first  stage  of  labor,  426. 

Pains : 
after-,  236. 
anomalies  of,  419. 
effect  of  chloroform  on,  220. 
good,  421,  449. 

in  abdominal  walls,  during  pregnancy,  91. 

in  puerperal  fever,  623. 

irregular,  in  first  stage,  421. 

irregular  in  second  stage,  426. 

irregulai-  in  third  stage,  429. 

premonitory,  130. 

strong,  420. 

weak,  420. 
l*alate,  cleft,  63. 
Palatine  arch,  63. 

Palpitation  of  heart  in  pregnancy,  117. 
Pancreas  : 

development  of,  66. 

dilatation  of  fetal,  517. 
Paresis  in  pregnancy,  95. 
Parametritis,  from  retroflexed  gravid  uterus, 
266. 

Parturition  {vide  labor). 
Pelvic  measurement,  434. 

external,  434. 

internal,  436. 

instruments  for,  485. 

of  conjugata  vera,  438. 

of  diagonal  conjugate,  437. 

of  external  conjugate,  436. 

of  transverse  diameter,  438. 
Pelvimeter,  435. 

circle  of  Baudclocquc,  435. 

Schultze's,  435. 

the  hand  as,  for  internal  measurements,  436. 
Pelvimetry  : 

external,  434. 

internal,  436. 

instruments  for,  435. 
Pelvis  : 

a,quabiUterjvst  :-minor,  432,  439. 
anatomy  of,  139. 
articulations  of,  143. 
as  a  whole,  148. 
contracted,  432. 

as  indication  for  aboi'tion,  326, 

diagnosis  of,  433. 
from  history,  434. 
fi-om  measurements,  436. 

efiects  in,  of  pressure  on  mother,  455. 


INDEX. 


679 


Pelvis : 

contracted,  effects  in,  of  pressure  on  child, 
456,  457. 
forms  of,  three  principal,  439. 
frequency  of,  432. 
generally,  444. 

influence  of,  in  pregnancy  and  labor,  446. 

on  labor-pains,  448. 

on  mechanism  of  labor,  451  et  seq. 

on  presentations  of  foetus,  448. 

on  uterus  in  pregnancy,  447. 
irregularly  : 

pseudo-osteomalacia,  445. 

kyphosis,  446. 

scoliosis,  446. 
prognosis  in,  459. 
treatment  in,  460. 

expectant,  475. 

forceps,  475. 

premature  labor,  467. 

version,  470. 

when  child  may  be  delivered  through 

natural  passages  alive,  466. 
when  child    can  not   be  delivered 
through  natural  passages  alive,  461. 
when  craniotomy  or  abortion  must  be 
performed,  464. 

varieties  of,  432. 
deformed,  rare  forms  of,  481. 
deformed  by — 

absence  of  symphysis,  499. 

exostosis,  498. 

fractures,  498. 

osteomalacia,  495. 

rachitis,  442. 
diameters  of,  150. 
differences  between — 

adult  and  infantile,  153. 

female  and  male,  152. 
flattened,  441. 

non-rachitic,  441. 

rachitic,  442. 
floor  of,  158. 
funnel-shaped,  493. 
inclination  of,  145. 
kyphotic,  485. 
ligaments  of,  145. 
measurements  of,  434. 
movements  in  joints  of,  147. 
Naegele's  oblique  {vide  oblique), 
nana,  439, 
osteomalacic,  495. 

anatomy,  morbid,  of,  495. 

diagnosis  of,  497. 

etiology  of,  496. 

prognosis,  497. 

treatment,  498. 
oblique,  of  Naegele,  481. 

anatomy,  morbid,  of,  481. 


Pelvis : 

diagnosis  of,  483. 

etiology  of,  482. 

mechanism  of  labor  in,  484. 

prognosis  in,  484. 

treatment  in,  485. 
planes  of,  149. 
pseudo-osteomalacic,  498. 
relaxation  of  symphysis  of,  in  pregnancy, 
273. 

Eobert' s  anchylosed  and  transversely  con- 
tracted, 489. 

anatomy,  morbid,  489. 

etiology,  490. 

prognosis,  491. 
soft  parts  of,  155. 
spondolisthetic,  491. 

anatomy,  morbid,  491. 

etiology,  492. 

prognosis,  493. 
Perforation : 
extraction  of  child  after,  382. 
indications  for,  377. 
instruments  for,  378  {'vicle  perforators), 
operation,  how  performed,  377,  381. 
preparations  for,  381. 
Perforator,  379. 
Blot's,  379. 

Hodge's  cranial  scissors,  379. 
Simpson's,  379. 
Smellie's  scissors,  378. 
Thomas's,  379. 
trephine,  380. 
Perinseum : 
dilatation  of,  in  labor,  133. 
laceration  of,  in  labor,  133. 
preservation  of,  in  labor,  207. 
rigidity  of,  obstructing  labor,  501. 
Peritonitis,  as  result  of  incarceration  of  retro- 
flexed  gravid  uterus,  266. 
Phantom  tumors,   differentiation  of,  from 

pregnancy,  105. 
Phlegmasia  alba  dolens^  655. 
etiology,  655. 
history,  clinical,  of,  656. 
origin  of,  655. 
prognosis  of,  657. 
treatment  of,  657. 
Phthisis,  complicating  pregnancy,  259. 
Physician,  visits  of,  during  the  puerperal 

state,  243. 
Placenta : 
anatomy  of,  49,  52, 
anomalies  of,  274. 
in  circulation,  274. 
in  development,  274. 
in  form,  274. 
in  position,  274. 
artificial  separation  of,  551. 


680 


INDEX. 


Placenta : 
development  of,  53. 
degenerations  of,  275. 
expression  of,  by  Crede's  method,  215. 

in  tardy  labor,  429. 
fetal,  54. 

inflammation  of,  275. 
new  growths  in,  275. 
prsevia,  552. 

diagnosis  of,  557. 
etiology  of,  553. 
frequency  of,  553. 
htemorrhages  in,  554. 
history,  clinical,  of,  554. 
prognosis  of,  556,  558. 
situation  of,  552. 
treatment  of,  557. 
Barnes's  dilator,  559. 
detachment  of  placenta,  560. 
ergot,  560. 
forceps,  560. 
tampon,  559. 
varieties  of,  552. 
retained,  550. 

treatment  of,  551. 
structure  of,  fully  developed,  55. 
syphilis  of,  276. 
tumors  in,  275. 
'uterina^  54. 
villi  of,  52. 
in  cat,  54. 
in  mare,  53. 
Placentitis,  275. 
Planes  of  pelvis,  149-151. 
Plates : 
abdominal,  47,  61. 
dorsal,  46,  59. 
lateral,  47,  61. 
vertebral,  primitive,  61. 
Pleurisy,  chronic,  complicating  pregnancy, 

258. 
Plexus : 
hypogastric,  27. 

pampiniformis,  23.  i 
uterinus,  23.  | 
magnus,  27.  ! 
Plicoe, : 

vesica- uterince,  14. 
rectO'Uterinoe,  15. 
Plural  pregnancy,  221  {vide  pregnancy,  mul- 
tiple). 

Pneumonia,  acute  lobar,  complicating  prcg-  ' 
nancy,  257.  I 
Podalic  version,  369.  I 
Polypus,  fibrinous,  removal  of,  308.  I 
Porro's  operation,  411  (vide  ovaro-hystorec- 
tomy). 
history  of,  412. 
details  of,  413. 


]  Portio  vaginalis  of  cervix,  12. 
i  Positions  : 

I     classification  of,  168. 
I     forceps,  use  of,  in  occipito-posterior,  352. 
I     fetal,  81. 
Post-partiim  haemorrhage,  539  {vide  haemor- 
rhage, post-partum). 
Prague,  method  of  extraction  with  head  at 

the  brim,  364. 
Pra&putium  clitoridis^  4. 
Precipitate  labor,  420  {vide  labor,  i)recipi- 

tate). 
Pregnancy : 
acardia,  in  multiple,  223. 
accidental  complications  of,  250. 
auscultation  in,  106. 
auscultatory  signs  of,  100. 
ballottement  in,  100. 

bladder  and  rectum,  functional  disease  of, 

in,  92. 
blood-changes  of,  116. 
breasts  in,  98. 

carbonic  dioxide,  increase  of,  in,  93. 
cardiac  diseases  in,  256. 
cephalalgia  in,  122. 
changes  in  abdominal  walls  in,  90. 
in  breasts  in,  91. 
in  cervix  uteri  in,  98. 
in  enth'e  organism  in,  92. 
in  navel  in,  90. 
in  nipple  in,  91. 
in  OS  uteri  in,  98, 

in  sexual  apparatus  and  neighboring  or- 
gans in,  82, 
in  thyroid  in,  93. 
in  vagina  in,  89. 
in  vulva  in,  89. 
cholera  complicating,  252. 
chorea  complicating,  261. 
complications  of,  accidental,  250. 
complicated  by  : 
anomalies  of  cord,  279. 
anomalies  of  placenta,  274. 
calcareous  degeneration  of  cord,  281. 
coiling  of  cord,  281. 
cysts  in  cord,  281. 
deficiency  of  amniotic  fluid,  278. 
hernias  of  cord,  280, 
hydatidiform  mole,  283. 
hydramnion,  277. 
knots  in  cord,  280. 
maceration  of  foetus,  288. 
missed  labor,  290. 
mummification  of  foetus,  288. 
placentitis,  275. 
retention  of  dead  foetus,  287. 
stenosis  of  umbilical  vessels,  281. 
torsion  of  cord,  279. 
conduct  of  labor  in  multiple,  228. 


INDEX. 


Pregnancy : 
diagnosis,  differential,  of,  104. 
diagnosis  of  dead  foetus  in,  109. 
diagnosis  of  multiple,  224. 
disorders  of,  116. 

distinction  between  first  and  second,  107. 
duration  of,  109. 

effects  of,  on  nervous  system,  95. 
emphysema  complicating,  258. 
empyema  complicating,  258. 
endometritis  during,  270,  272. 
extra-uterine,  309. 

abdominal,  310,  315. 

definition  of,  310. 

diagnosis  of,  318. 

interstitial,  313. 

ovarian,  310,  315. 

puncture  of  sac  in,  319. 

symptoms  of,  316. 

terminations  of,  317. 

tubal,  310. 

tubo-abdominal,  314. 

tubo-ovarian,  314. 

treatment,  319. 
of  early  cases,  319. 
of  advanced  cases,  322. 
face-ache  in,  121. 
fetal  heart-sounds  in,  100. 
funic  souffle  in,  102. 
frequency  of  multiple,  221. 
heart-burn  in,  121. 
hydraemic  cedema  in,  117,  118. 
hygiene  of,  115, 
icterus  complicating,  255. 
impaired  digestion  in,  94. 
increase  in  size  of  abdomen  in,  98. 
insalivation  in,  121. 
insanity  in,  652. 
insomnia  in,  122. 
inspection  of  abdomen  in,  103. 
interrogation  of  patient  in,  102. 
interruption,  premature,  of,  291. 
malarial  fever  in,  254. 
management  of,  115. 
methods  of  physical  examination  in,  102. 
multiple,  221. 

acardia  in,  223. 

conduct  of  labor  in,  228. 

development,  unequal,  in,  223. 

diagnosis  of,  224. 

foetus  papyraceus  in,  224. 

frequency  of,  221. 

labor  in,  225. 

locking  of  children  in,  227. 
origin  of,  221. 
presentations  in,  225. 
prognosis  in,  228. 
weight  of  children  in,  223. 
varieties  of,  221. 


Pregnancy : 
naasea  and  vomiting  in,  97,  119. 
oedema  in,  92,  118,  535. 
palpation  of  abdomen  in,  103. 
pathology  of,  249. 

pernicious  anasmia  complicating,  117. 

phthisis  complicating,  259. 

pneumonia  complicating,  257. 

pleurisy  complicating,  258. 

prediction  of  end  of,  111-113. 

pruritus  in,  121. 

quickening  in,  99. 

rectal  touch  in,  107. 

relapsing  fever  complicating,  253. 

relaxation  of  symphysis  in,  273. 

rubeola  complicating,  251. 

salivation  in,  98. 

scarlatina  complicating,  251. 

speculum,  use  of,  in,  107. 

suppression  of  menses  in,  96. 

sm-gical  operations  during,  262. 

sympathetic  diseases  in,  97. 

syphilis  complicating,  259. 

typhoid  fever  complicating,  253. 

typhus  fever  complicating,  253. 

urine,  increase  of,  in,  95. 

uterine  bruit  in,  100,  101. 

vaginal  touch  in,  106. 

varicose  veins  in,  118. 

variola  complicating,  250. 
Premature  labor,  291,  420  {vide  labor,  p.  6 
Preparations  for  labor,  203. 
Presentations,  78,  167. 

breech,  196. 

armamentarium  for,  355. 
causes  of,  196. 

configuration  of  foetus  in,  200. 

diagnosis  of,  196. 

exceptional  cases  of,  361. 

extraction  of  head  in,  362,  363. 

extraction  in,  354. 

irregularities  in  mechanism  of,  199. 

liberation  of  arms  in,  360. 

management  of  cord  in,  359. 

mechanism  of,  197. 

operation  of  extraction  in,  356,  357. 

prognosis  in,  200. 

release  of  arms  in,  360. 

treatment  of,  201. 
brow,  192. 

prognosis  in,  193. 

treatment  of,  194. 
cause  of  predominating,  first,  169. 
classification  of,  168. 
face,  182, 

causes  of,  182. 

forceps  in,  353. 

configuration  of  head  in,  188. 

diagnosis  of,  189. 


682 


INDEX. 


Presentations,  face  : 

frequency  of,  182. 

mechanism  of,  184,  186. 

prognosis  in,  189. 

treatment  of,  190. 
natural,  167. 
normal,  167. 

pelvic,  extraction  in,  354. 
shoulder,  167,  465. 

version  in,  465. 
transverse,  167. 
unnatural,  167. 
vertex,  168. 

frequency  of,  168. 

diagnosis  of,  168. 

theories  to  account  for  preponderance  of, 
79. 

Prolapse : 

of  gravid  uterus,  268. 

of  vagina  in  pregnancy,  268. 
Primitive  trace,  46,  59. 
Process,  frontal  or  intermaxillary,  62. 
Protosoma^  46. 

Pruritus  in  pregnancy,  95,  121. 
Psoas  abscess  in  puerperal  fever,  626. 
Pseudo-osteomalacic  pelvis,  498. 
Pubes,  anatomy  of,  142. 
Pudendum,  definition  of,  1. 
Puerperal  diseases,  602. 
Puerperal  eclampsia,  526  {vide  eclampsia). 
Puerperal  fever,  602. 
abscesses  in,  625. 
bacteria  in,  612  et  seq.^  631. 
causes  of,  630,  633,  636,  637. 
classification  of  lesions  of,  603. 
clinical  history  of,  620  et  seq. 
symptoms  of  endocolpitis  and  of  endome- 
tritis, 620. 
symptoms  of  general  peritonitis,  626. 
symptoms  of  parametritis,  621. 
symptoms  of  perimetritis,  621. 
symptoms  of  septicaemia,  628-630. 
definition  of,  602. 
diphtheritic  patches  in,  617,  631. 
endocarditis  in,  618. 
endocolpitis  in,  604,  620. 
endometritis  in,  604,  620. 
erysipelas,  how  related  to,  618. 
frequency  of,  602,  640. 
inflammation : 
of  genital  mucous  membrane  in,  603,  604. 
of  peritonaeum,  uterine,  604,  607,  626. 
of  subserous  pelvic  cellular  tissue  in,  603, 
607. 

of  uterine  parenchyma  in,  603,  605. 
lesions  of,  603. 
metritis  in,  605,  621. 
micrococci  in,  612,  631. 
microspores  in,  612,  031. 


Puerperal  fever : 
nature  of,  608, 

pathological  anatomy  of,  603. 

phlebitis  in,  604,  607,  629. 

phlebo-thrombosis  in,  607. 

prevention  of,  637,  641. 

septicaemia  in,  604,  608,  611,  619,  628,  630. 

treatment  of,  643. 

by  alcohol,  648. 

by  antipyretics,  646. 

by  cold,  648. 

by  digitalis,  647. 

by  douche,  intra-uterine,  643. 

by  douche,  vaginal,  643. 

by  laxatives,  646. 

by  leeches,  646. 

by  opium,  645. 

by  poultices,  646. 

by  quinia,  646. 

by  salicylate  of  soda,  647. 

by  veratrum  viride,  647. 
treatment  of  peritoneal  effusions,  650. 
virus  of,  612. 
Puerperal  state,  230. 
after-pains  in,  235. 
cervix  uteri  in,  234. 
closure  of  sinuses  in,  234. 
diagnosis  of,  240. 
diet  in,  244. 

general  functions  in,  231. 
involutio  uteri  in,  232. 
lochia  in,  236. 
loss  of  weight  in,  232. 
management  of,  217,  242. 
milk-fever  in,  238. 
nursing  in,  245. 
passing  urine  in,  242. 
pulse  in,  231. 
retention  of  urine  in,  232. 
separation  of  decidua  in,  233. 
secretion  of  milk  in,  237. 
sleep  in,  242. 
temperature  in,  231. 
uterus,  position  of,  in,  235. 
vagina  in,  235. 
visits  of  physicians  in,  243. 
washing  of  vagina  in,  243. 
Pulse,  in  puerperal  state,  231. 

Quickening,  date  of,  113. 
Quinine  : 

as  antiphlogistic,  in  puerperal  fever,  646. 

Rachitis : 

deforming  pelvis,  442,  445. 
Ecctocele : 

atresia,  vaginal,  from,  502. 
Eelapsing  fever: 

complicating  pregnancy,  253. 


INDEX. 


683 


Kepercussion  {vide  ballottement). 
Eepositor : 
Braun's,  375. 
Eoberton's,  5S7. 
catheter,  used  as,  376. 
Eespiration : 

artificial,  in  asphyxia,  595. 
Marshall  Hall's  method,  596. 
Schultze' s  method,  595. 
Eestitution,  in  vertex  presentations,  176  {vide 
external  rotation), 
in  face  presentations,  186. 
Eetained  placenta,  550  {vide  placenta,  re- 
tained). 
Eetention : 
in  ntero^  of  dead  foetus,  287. 
of  urine — 
in  pregnancy,  502. 
in  puerperal  state,  232. 
Eetroflexion  of  gravid  uterus,  265. 
with  incarceration,  266. 
treatment  of,  267. 
Eetroversion  of  gravid  uterus,  265. 
Eickets : 

causing  pelvic  deformity,  442,  445  {vide 
rachitis). 
Eigid  OS : 

atresia  from,  505. 
Bima  pudendi^  2. 
Eobert's  anchylosed  pelvis,  489. 
Eotation  of  foetus  : 

in  breech  presentations,  193. 

in  face  presentations,  186. 

in  vertex  presentations,  176. 
Eubeola,  complicating  pregnancy,  251. 
Eupture : 

at  orifice  of  vagina,  575. 

of  genital  canal,  564. 

of  pelvic  articulations,  581,  582. 

of  perinaeum,  576. 

of  uterus,  564  {vide  uterus,  rupture  of  the), 
of  vagina,  575. 
of  vestibule,  575. 

Sac: 

injections  into,  in  extra-uterine  pregnancy, 
320. 

puncture  of,  in  extra-uterine  pregnancy,  319. 
Sacro-iliac  articulation,  143. 
Sacrum : 

anatomy  of,  139. 

superficies  auricularis  of,  141. 
Salicylate  of  soda  in  puerperal  fever,  647. 
Salivation  in  pregnancy,  121. 
Scarlatina : 

in  pregnancy,  251. 

puerperalis,  252. 
Schinnis,  of  uterus : 

obstructing  labor,  509  {vide  atresia,  uterine). 


1  Scholiotic  pelvis,  446. 
Scholio-rachltic  pelvis,  488. 
Seasons,  relation  of,  to  puerperal  fever,  637. 
Section, Cesarean,  Z'd^{vide  Csesarean  section). 
Secretion  : 

disorders  of,  in  pregnancy,  121. 
Segmentation  of  ovum,  43. 
Semen,  41. 
Senses,  special : 

affections  of,  in  pregnancy,  95,  97. 
Septictemia : 

in  puerperal  fever,  604,  608,  611,  620. 

symptoms  of,  628  et  seq. 
Septum  : 

recto-vaginale^  7.  » 
xirethro-vaginale^  7. 
Serous  lochia,  236. 

Serves  jines^  in  perineal  laceration,  578. 
Shoulder  presentations  {vide  transverse  pres- 
entation). 
Shoulders,  delivery  of,  211. 
Sinus  terminalis^  67. 

Sinuses,  closure  of,  in  puerperal  state,  234. 
Sleep,  in  puerperal  state,  242. 
Sleeplessness,  in  pregnancy,  122. 
Smegma  prcepidii^  5. 

Social  state,  relation  of,  to  puerperal  fever, 
637. 

Souffle,  funic,  102. 

Speculum,  use  of,  in  pregnancy,  107. 

Spermatozoa,  41. 

Sphincter  vaginae,  9. 

Spina  bifida,  61. 

as  obstruction  to  labor,  51 7. 
Spinal  column,  articulation  of  fetal  head  with, 

166. 
Spleen : 

enlargement  of  fetal,  517. 
Spondolisthetic  pelvis,  491. 
Spontaneous  evolution,  523  {vide  evolution). 
Spontaneous  version,  521  {vide  version). 
Spot  : 

embryonic,  46,  59. 
I     germinative,  of  ovum,  37. 
Stage  of  labor : 
irregular  pains  in  first,  419. 
irregular  pains  in  second,  426. 
irregular  pains  in  third,  429. 
management  of  first,  204. 
management  of  second,  205. 
delivery  of  shoulders  in,  211, 
preservation  of  perinaeum  in,  207. 
tying  cord  in,  211. 
management  of  third,  215. 
treatment  of  long  first,  423. 

by  anodynes  and  anaesthetics,  424. 

by  Barnes's  dilators,  425. 

by  bougies,  425. 

by  douche,  vaginal,  425. 


684 


INDEX. 


State,  the  puerperal,  230. 
after-pains  in,  236. 
cervix,  the,  in,  234. 
chill  in,  230. 

closure  of  sinuses  in,  234. 
diagnosis  ot,  240. 
diet  in,  244. 

general  functions  in,  231. 
involution  in,  232. 
laxatives  in,  244. 
lochia  in,  236. 
loss  of  weight  in,  232. 
management  of,  242. 
milk-fever  in,  238. 
nursing  in,  245. 
passing  urine  in,  243. 
pulse  in,  231. 

relations  of,  to  pathological  conditions, 
230. 

retention  of  urine  in,  232. 
scarlatina  in,  252. 
secretion  of  milk  in,  236. 
sleep  in,  242. 

uterus,  position  of,  in,  235. 

vagina  in,  235. 

visits  of  physician  in,  243. 

washing  vagina  in,  243. 
Stenosis  : 

of  umbilical  vessels,  281. 
Stigma  follicuU^  37. 
Stimulants : 

in  cerebral  anaemia,  547. 
Strait : 

axis  of  inferior  pelvic,  151. 

axis  of  superior  pelvic,  150. 

forceps  at,  348. 

inferior  pelvic,  150. 

superior  pelvic,  149. 
Strioe : 

abdominal,  in  pregnancy,  91. 
Styptics : 

in  post-partum  haemorrhage,  54. 
Superfecundation,  221  {vide  pregnancy,  mul- 
tiple). 

Superficies  auricularis^  141. 
Surgery,  obstetric,  326. 
Surgical  operations  : 

during  pregnancy,  262. 
Suspended  animation,  588  {vide  asphyxia  neo- 
natorum). 
Sutures : 

coronal,  77,  163. 

frontal,  77,  163. 

lambda,  77,  163. 

premature  ossification  of,  513. 

sagittal,  77,  163. 
Symphysis  pubis : 

absence  of,  499. 

anatomy  of,  145. 


Symphysis  pubis : 

relaxation  of,  in  pregnancy,  273. 

rupture  of,  581. 
Syncope : 

in  childbed,  597. 

in  labor,  597. 

in  pregnancy,  95,  117. 

Tampon : 

in  abortion,  305. 

in  placenta  prsevia,  559. 

method  of  applying,  305. 

to  produce  premature  delivery,  332. 
Tardy  labors,  421  {vide  labor,  tardy). 
Temperature : 

in  post-pai'ttim  state,  231. 
Testicle : 

fibro-cystic  degeneration  of  fetal,  517. 
ThecafoUiculi  : 

of  Graafian  follicle,  35. 
Thrombus : 
causing  collapse  and  death  in  labor  and 

childbed,  597. 
in  veins  and  lymphatics,  during  phlegma- 
sia, 655. 
of  OS,  in  labor,  505. 

of  vagina,  578  {vide  vagina,  thrombus  of). 

of  vulva,  578  {vide  vulva,  thrombus  of). 
Tenesmus,  vesical,  from  retroflexed  incarce- 
rated gravid  uterus,  266. 
Torsion  of  cord,  279. 
Trace,  primitive,  46,  59. 
Tractions  on  forceps,  346. 

direction  of,  347. 

time  for  making,  346. 
Transforateur.,  Hubert's,  in  cephalotomy,  394. 
Transfusions,  of  blood  and  milk,  in  post-par- 
tum htemorrhage,  548. 
Transverse  presentations,  167. 
Trunk : 

delivery  of,  with  crotchet,  393. 

expulsion  of,  in  labor,  177. 
Tubal  pregnancy,  310. 
Tubes,  Fallopian : 

ampulla  of,  19. 

anatomy  of,  18. 

isthmus  of,  19. 

ostium  abdominale  of,  19. 
Tubus  : 

intestinalis,  62. 

medullaris,  47,  60. 
Tumors : 

abdominal,  diagnosis  of,  from  pregnancy, 
512. 

fetal,  causing  dystocia,  517. 
osseous,  deforming  pelvis,  498. 
ovarian,  511  {vide  ovary,  tumor  of). 

in  parturition,  512. 

in  pregnancy,  511. 


INDEX. 


685 


Tumors,  ovarian  : 

in  puerperal  state,  512. 
obstructing  labor,  511. 
parametritic,  in  puerperal  fever,  624,  625. 
phantom,  difterentiation  of,  from  preg- 
nancy, 105. 
scalp,  179. 
uterine : 

complicating  pregnancy,  parturition  and 

puerperal  state,  506. 
producing  atresia,  505. 
Tunica : 
albuginea,  of  ONiim,  21. 
.Jibrosa^  of  Graafian  follicle,  35. 
propria,  of  Graafian  follicle,  35. 
Turning  {vide  version). 
Twins : 

locking  of,  obstructing  labor,  227. 
Twin-pregnancy  {vide  pregnancy,  multiple). 
Tympanites : 

in  puerperal  fever,  627,  628. 

uteri,  601. 

Typhoid  fever,  complicating  pregnancy,  253. 
Typhus  fever,  complicating  pregnancy,  253. 

Umbilical  cord,  57  {vide  funis), 
anomalies  of,  279. 
calcareous  degeneration  of,  281. 
care  of,  in  infants,  246. 
coiling  of,  281 . 
cysts  in,  281. 
diseases  of,  28. 
formation  of,  57. 
hernias  of,  280. 
knots  in,  280. 

management  of,  in  breech  presentations,  359. 

marginal  insertion  of,  282. 

prolapse  of,  582. 

reposition  of,  587. 

souflfle  in,  102. 

stenosis  of  vessels  of,  281. 

torsion  of,  279. 

tying  of,  in  labor,  211. 
Umbilical  vesicle,  47. 
Umbilical  vessels : 

stenosis  of,  281. 
Umbilicus : 

changes  of,  in  pregnancy,  90,  103. 

of  new-born  child,  241. 
Unavoidable  haemorrhage,  554. 
Uraemia : 

in  eclampsia,  529,  532. 
Ureter : 

development  of  fetal,  516. 
Urinary  calculus : 

obstructing  labor,  502. 
Urine : 

albumen  in,  during  pregnancy,  95. 
during  eclampsia,  528,  529,  531. 


I  Urine: 

atresia  from  retention  of,  502. 
increase  of,  in  pregnancy,  95. 
passing,  in  puerperal  state,  243. 
retention  of,  in  pregnancy,  502. 
retention  of,  in  puerperal  state,  232. 
Uterine : 
bruit,  in  pregnancy,  101. 
glands,  16. 
inertia,  422. 

pain,  in  pregnancy,  130. 
tumors,  obstructing  labor,  505. 
Uterus : 
abnormalities  of,  29. 
abnormal  conditions  of,  263. 
anatomy  of,  11. 

anteversion  and  anteflexion  of,  264. 
atrophy  of  mucous  membrane  of,  causing 

abortion,  292. 
licornis,  32. 
body  of,  12. 

bruit  in,  during  pregnancy,  101. 
cancer  of  neck  of,  509. 

treatment  of,  510. 
catheterization  of,  to  produce  abortion,  329. 
cavity  of  body  of,  1 2. 
cervix  or  neck  of,  12. 
contractions  of— 
eifect  of  chloroform  on,  220. 
cordiformis,  32. 
corpus  of,  12. 
didelpliys,  30. 
dilatation  of  fetal,  517. 
double,  263. 
duplex,  30. 
fundus  of,  12. 
glands  of,  16. 
gravid : 

anteversion  and  anteflexion  of,  264. 
retroflexion  of,  265. 
retroversion  of,  265. 
with  incarceration,  266,  267. 
hernia  of,  269. 

hour-glass  contraction  of,  429. 
hypersemia  of  gravid,  294. 
hypertrophy  of  mucous  membrane  of,  293. 
injections  between,  and  ovum  to  produce 

abortion,  329. 
injections  into,  in post-partum  haemorrhage, 

544. 

inversion  of,  563. 
laceration  of  cervix  of,  573. 
ligaments  of,  14. 
lymphatics  of,  27. 
myomata  of,  506,  508. 
nerves  of,  27. 
neck  of,  12. 

perforation  of,  from  pressure,  573. 
position  of,  in  puerperal  state,  235. 


686 


INDEX. 


Uterus : 

prolapse  of,  268. 
rupture  of,  564. 

clinical  history  of,  569. 

diagnosis  of,  569. 

etiology  of,  565. 

pathology  of,  568. 

treatment  of,  570  et  seq. 
semi-partitus^  32. 
septus  bilocularis^  32. 
tumors  of,  complicating  pregnancy,  506. 
tympanites  of,  001. 
unicornis,  30. 
veins  of,  23. 

vessels  of,  and  of  its  appendages,  22. 

Vagina : 

atresia  of,  501. 

accidental,  501. 

congenital,  501. 

from  cystic  degeneration,  503. 

from  cystocele,  502. 

from  echinococci,  503, 

from  neoplasmata,  503. 

from  rectocele,  502. 

from  retention  of  urine,  502. 

from  vaginal  hernia,  503. 

from  vaginismus,  503. 

from  vesical  calculi,  502. 
anatomy  of,  7. 
arteries  of,  11. 
bulbs  of  vestibule  of,  4. 
changes  of,  in  pregnancy,  89. 
changes  of,  in  puerperal  state,  235. 
columns  of,  9. 
cristce  of,  9. 

cystic  degeneration  of,  503. 
double,  263. 
douche  in,  425. 

examination  by,  in  pregnancy,  203. 
laceration  of,  575. 
laceration  of  orifice  of,  575. 
prolapse  of,  in  pregnancy,  268. 
sphincter  of,  9. 
structure  of  walls  of,  8, 
tampon  applied  to — 
in  abortion,  305. 

in  post-partum  hfemorrhage,  559. 

to  produce  abortion,  332. 
thrombus  of,  578. 

diagnosis  of,  579. 

etiology  of,  579. 

prognosis  of,  580. 

symptoms  of,  578. 

treatment  of,  580. 
veins  of,  11. 

walls  of,  their  structure,  8. 
Vaginal  douche,  425,  331,  642. 
Vaginal  growths,  atresia  from,  503. 


Vaginismus : 

atresia  from,  503. 
Vagitus  uterinus^  601. 
Valve : 

Eustachian,  68. 

of  foramen  ovale^  09. 
Varicose  veins  in  pregnancy,  118. 
Variola  in  pregnancy,  250. 
Veins: 

of  uterus,  23. 

of  vagina,  11. 

varicose,  in  pregnancy,  92,  118. 
Veratrum  viride : 

in  puerperal  fever,  647. 
Vernix  caseosa^  75. 
Version,  366. 

after  craniotomy,  394. 
after  complete  retraction  of  uterus,  375. 
after  rupture  of  membranes,  374. 
cephalic,  366. 

Braxton  Hicks' s  method,  369. 

Bosch's  method,  368. 

combined  methods,  368. 

D'Outrepont's  method,  368. 

external  method,  367. 

Hohl's  method,  369. 

Wigand's  method,  307. 

Wright's  method,  368. 
combined  with  abortion,  406. 
external,  300. 
hand,  employed  in,  372. 
in  contracted  pelves,  470,  477,  479. 
in  head  presentations,  372. 
in  lateral  positions,  372. 
in  prolapse  of  funis,  584,  587. 
in  rupture  of  uterus,  572. 
in  transverse  presentations,  373, 
use  of  catheter  as  repositor  in,  376, 
use  of  fillet  in,  375. 
use  of  repositor,  Braun's,  in,  375. 
internal,  371. 
neglected,  375. 
podalic,  309, 

bipolar  method,  309. 

combined  method,  369. 

indications  for,  369. 
spontaneous,  521. 

etiology,  521. 

mechanism  of  complete,  523. 
mechanism  of  partial,  522. 
prognosis  in,  523. 
Vertex  presentation,  168  {vide  presentation, 

vertex). 
Vertebrae,  primitive,  61. 
Vesicle : 
blastodermic,  44. 
germinative,  of  ovum,  37. 
umbilical,  47. 
Vesicles,  cerebral,  60. 


INDEX. 


687 


Vessels : 

collapse  and  death  from  entrance  of  air  into 
utei-ine,  598. 

umbilical,  stenosis  of,  281. 

uterine,  22. 
Vestibulam^  4. 

bulbce  of,  4. 

glandulce  of,  5,  6. 

laceration  of,  575. 
Villi,  cliorial,  50,  52. 

Vinegar,  'm.  post-part um  hsemorrhage,  545. 
Virus,  of  puerperal  fever,  612. 
Visceral  arches,  62. 

aortic  arches,  67. 
Visceral  clefts,  62. 

Visits  of  physician,  in  puerperal  state,  243. 
Vitelline  artery,  67. 
Vitelline  membrane  of  ovum,  36. 
Vitellus,  or  yolk,  of  ovum,  37. 
Vomiting : 

in  incarcerated  retroflexed  gravid  uterus, 
266. 

in  pregnancy,  119. 
in  puerperal  fever,  623. 
induction  of  abortion  for,  120. 
Vulva : 
atresia  of,  500. 

changes  of,  in  pregnancy,  89. 


Vulva : 
connivens^  2. 
frenulum  of,  4. 
hians^  3. 

laceration  of,  575. 
mucous  glands  of,  5. 
oedema  of, 

in  labor,  130,  535. 

in  pregnancy,  118,  266. 
Vulvo-vaginal : 
folUcles,  5,  6. 
glands,  5,  6. 

Weight : 

loss  of,  in  puerperal  state,  232. 

of  foetus,  at  term,  76. 

of  foetus,  in  multiple  pregnancy,  223. 
Wet-nurse : 

selection  of,  246. 
Wet-pack  : 

use  of,  in  puerperal  fever,  649. 
Wharton's  gelatine,  57. 
Wolffian  bodies,  28. 

Yolk  of  ovum,  37. 

Zona  pellucida  of  ovum,  37. 
Zymotic  diseases : 
their  relation  to  puerperal  fever,  636. 


THE  END. 


THE 


Science  and  Art  of  Midwifery. 

By  WILLIAM  THOMPSON  LUSK,  M.  A.,  M.  D., 

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will  not  be  considered  as  two  distinct,  independent  subjects,  but  the 
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Surgeon-General  U.  S.  Arimj  {retired  list)  ;  Professor  of  Diseases  of  the  Mind  and  Nervous  System 
in  the  University  of  the  City  of  New  York,  etc.,  etc. 


Seventh  edition,  rewritten,  enlarged,  and  improved.    In  one  large 
8vu  volume  of  929  pages,  with  complete  Index  and  113  Illus- 
trations. Price,  cloth,  $5.00  ;  sheep  or  half  russia,  $6.00. 


This,  the  seventh  edition  of  Dr.  Hammond's  well-known  work,  has  been  thoroughly 
revised,  and  enlarged  by  the  addition  of  new  chapters,  and  of  a  section  on  Diseases  of 
the  Sympathetic  System. 

The  work  has  received  the  honor  of  a  French  translation  by  Dr.  Labadie-Lagrave,  of 
Paris,  and  an  Italian  translation  by  Professor  Diodato  Borrelli,  of  the  Royal  University, 
is  now  going  through  the  press  at  Naples. 


"Dr.  Hammond's  work  has  now  been  before  the  profession  for  many  years,  and  its 
characteristics  are  very  generally  known.  The  present  edition  has  a  good  many  valuable 
additions,  but  has  lost  nothing  of  its  previous  individuality  as  a  medical  work.  Dr. 
Hammond  has  the  qualities  of  a  successful  author.  He  has  extensive  knowledge,  though 
it  is  more  varied  than  profound.  His  practical  experience  is  large,  his  convictions  are 
positive,  and  he  can  set  them  forth  clearly  and  attractively.  It  is  not  surprising  that  his 
book  has  been  a  very  popular  one.  And  the  present  edition  is,  as  modestly  stated  on 
the  title-page,  '  improved.'  " — Medical  Record. 

"Our  space,  and  indeed  the  very  nature  of  the  work,  forbids  a  detailed  notice  of  the 
book.  Suffice  it  to  say  that  we  are  convinced,  from  a  by  no  means  superficial  examina- 
tion of  it,  that  there  is  no  work  on  the  subject  better  entitled  to  the  wants  of  the  general 
practitioner  at  least." — Michir/an  Medical  News. 

"The  author  has  a  captivating  style  of  writing,  in  the  first  place  from  the  clearness 
of  it,  and,  in  the  second,  from  the  graphic  manner  of  his  illustrations  with  which  every 
chapter  abounds.  His  particular  strength  is  in  depiction,  Hammond  is  undeniably  an 
artist  in  his  profession,  and  he  touches  up  the  most  somber  backgrounds  with  bits  of 
enlivening  color.  Some  chapters,  like  that  on  epilepsy,  have  almost  the  fascination  of 
romance.  But,  as  we  have  already  said,  the  profession  is  thoroughly  familiar  with  all 
the  strong,  and  we  might  add  the  weak  points  of  this  book,  so  that  anything  like  a  criti- 
cal review  of  it  is  unnecessary." — Lancet  and  Clinic. 

"  During  the  five  years  which  have  elapsed  since  the  publication  of  the  sixth  edition 
of  this  standard  work  on  diseases  of  the  nervous  system,  investigations  in  this  special 
department  of  pathology  have  been  pushed  with  remarkable  activity  and  vigor,  both  in 
this  country  and  abroad.  New  and  improved  instruments  are  constantly  coming  into  use, 
enabling  the  physician  to  interpret  accurately  symptoms  which  formerly  Avere  obscure, 
and  consequently  make  his  treatment  more  rational.  Among  those  who  have  contributed 
largely  to  this  rapid  advancement,  few  are  more  widely  known  than  Dr.  Hammond,  and 
we  feel  assured  that  this  new  edition,  which  has  been  thoroughly  revised  and  enlarged 
by  the  addition  of  much  that  is  new,  will  receive  a  hearty  welcome  from  the  medical  pro- 
fession on  both  sides  of  the  Atlantic.  The  author  is  a  concise  writer,  who  never  wastes 
any  paper,  and  he  has,  as  he  says  himself  in  his  preface,  views  of  his  own  on  every  dis- 
ease considered,  and  he  is  not  afraid  to  express  them ;  in  short,  the  work  is  largely  the 
result  of  his  own  observation  and  experience,  though  the  labors  of  others  are  by  no 
means  ignored." — Medical  and  Surgical  Reporter  {Philadelphia). 


D.  APPLETON  &  CO.,  Publishers, 

1,  3,  &  5  Bond  Street,  New  York, 


ISrOW  READY. 


THE 

AjjlieflADatmyoftle  Moos  System; 

BEING 

A  Study  of  this  Portion  of  the  Human  Body  from  a  Standpoint  of 
its  General  Interest  and  Practical  Utility. 

Designed  for  Use  as  a  Text-book  and  as  a  Work  of  Reference. 

By  AMBROSE  L.  RANNEY,  A.  M.,  M.  D., 

Adjunct  Professor  of  Anatomy  and  late  Lecturer  on  the  Diseases  of  the  Genito-TTrinary  Orj^ans  and  on 
Minor  Surgery  in  the  Medical  Department  of  the  University  of  the  City  of  New  York;  late 
burgeon  to  the  Northern  and  Northwestern  Dispensai-ies ;  Resident  Fellow  of  the 
New  York  Academy  of  Medicine ;  Member  of  the  Medical  Society  of  the 
County  of  New  York ;  author  of  "  A  Practical  Treatise  on  Sur- 
gical Diagnosis,"  "The  Essentials  of  Anatomy,"  etc. 


PROFUSELY  ILLUSTRATED. 


Price,  clotl:\,  $4.00    -      -      -      -      -      -      -      sheep,  $5.00. 


The  publishers  take  pleasure  in  presenting  this  book  to  the  medical  profession  as  a 
valuable  aid  to  the  study  of  advanced  works  upon  diseases  of  the  nervous  system.  In 
no  branch  of  medical  science  has  there  been  more  progress  within  the  past  few  years  than 
in  this  special  department.  A  knowledge  of  the  anatomy  and  physiology  of  the  nervous 
system,  as  it  has  been  developed  of  late  by  experimental  research  and  pathological  in- 
vestigation, is  essential  to  every  one  who  expects  to  master  the  diagnosis  of  nervous 
affections.  New  terms  are  now  commonly  met  with  in  all  the  later  treatises  upon  this 
branch,  which  can  be  properly  appreciated  only  by  the  study  of  a  work  similar  to  that 
now  offered. 

The  volume  presented  is  based  upon  an  extended  course  of  lectures  delivered  before 
a  class  of  medical  students,  and  is  eminently  practical  in  its  nature,  being  within  the 
comprehension  even  of  beginners,  although  nothing  has  been  spared  to  make  the  subject- 
matter  full  up  to  date. 

The  illustrations  have  been  selected  from  the  most  beautiful  of  the  cuts  of  Sappey, 
Hirschfeld,  Masse,  and  others,  while  numerous  diagrams  are  interspersed  to  make  all  in- 
volved or  obscure  points  doubly  clear  to  the  reader. 

The  brain  and  spinal  cord  have  been  so  treated  of  as  to  assist  the  reader  in  mastering 
the  art  of  localizing  cerebral  and  spinal  lesions  during  life.  The  different  types  of  paral- 
ysis are  treated  of  at  some  length  from  an  anatomical  standpoint,  and  the  mechanism  of 
their  symptomatology  is  discussed  in  such  a  way  as  to  prove  attractive  to  the  student 
and  to  assist  the  practitioner  in  diagnosis. 

The  diagnostic  value  of  pain  is  considered  in  connection  with  individual  nerves,  and 
the  various  forms  of  neuralgias  are  also  exhibited  in  such  a  form  as  to  impress  upon  the 
reader  the  various  causes  of  each,  as  Well  as  the  situation  of  the  points  of  tenderness  to 
pressure,  which  will  aid  in  their  discrimination. 

In  connection  with  the  cranial  nerves,  much  that  pertains  to  the  physiology  of  the 
acts  of  siucll,  sight,  hearing,  taste,  speech,  swallowing,  vomiting,  etc.,  is  concisely  stated  ; 
while  the  numerous  diagrams  incorporated  will,  it  is  believed,  greatly  assist  in  clearly 
presenting  the  special  functions  of  individual  branches  of  these  important  nerves. 

The  publishei-s  believe  that  no  Avork  of  this  character  has  yet  appeared  in  our  lan- 
guage which  so  fully  embraces  all  the  late  researches  of  the  German,  French,  and  English 
investigators,  and  they  expect  it  to  prove  a  valuable  supplement  to  standard  works  upon 
nervous  diseases,  as  well  as  a  useful  text-book  for  the  medical  student. 

D.  APPLETON  &  CO.,  Publishers, 

1,  3,  &  S  Bond  Street,  New  York. 


MEDICAL  AND  HYGIENIC  WORKS 


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4 


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